An amusing press release from the governing body for American surgeons:
The American College of Surgeons is deeply disturbed over the uninformed public comments President Obama continues to make about the high-quality care provided by surgeons in the United States. When the President makes statements that are incorrect or not based in fact, we think he does a disservice to the American people at a time when they want clear, understandable facts about health care reform. We want to set the record straight.
-- Yesterday during a town hall meeting, President Obama got his facts
completely wrong. He stated that a surgeon gets paid $50,000 for a leg
amputation when, in fact, Medicare pays a surgeon between $740 and
$1,140 for a leg amputation. This payment also includes the
evaluation of the patient on the day of the operation plus patient
follow-up care that is provided for 90 days after the operation.
Private insurers pay some variation of the Medicare reimbursement for
this service.
-- Three weeks ago, the President suggested that a surgeon's decision to
remove a child's tonsils is based on the desire to make a lot of
money. That remark was ill-informed and dangerous, and we were
dismayed by this characterization of the work surgeons do. Surgeons
make decisions about recommending operations based on what's right for
the patient.
We agree with the President that the best thing for patients with diabetes is to manage the disease proactively to avoid the bad consequences that can occur, including blindness, stroke, and amputation. But as is the case for a person who has been treated for cancer and still needs to have a tumor removed, or a person who is in a terrible car crash and needs access to a trauma surgeon, there are times when even a perfectly managed diabetic patient needs a surgeon. The President's remarks are truly alarming and run the risk of damaging the all-important trust between surgeons and their patients.
We assume that the President made these mistakes unintentionally, but we would urge him to have his facts correct before making another inflammatory and incorrect statement about surgeons and surgical care.
I agree with the sentiment here (Obama shouldn't be telling people to distrust their doctors, even if all of them aren't always acting in your best interest). He was right about the tonsillectimy thing, though. Here's a random abstract on the subject:
Objective: Unilateral tonsillar enlargement (UTE) may be a sign of underlying malignancy and tonsillectomy is often recommended for histology. The limited evidence available suggests that the incidence of malignancy in children with UTE is very low, and that in many cases, the apparent enlargement is due to asymmetry of the mucosa of the tonsillar pillars. The purpose of this study was to evaluate the necessity of tonsillectomy as a routine practice for every case of UTE. Methods: We attempted to identify every child (age
There is a genuine debate about unnecessary tonsillectamy w/in the surgical community, but it's not really something Obama should personally weigh in on. However, the health debate is abstract enough as is so it's understandable to want to come up with anecdotes to back up claims of saving money by eliminating unnecessary procedures.
You have got to be kidding me right????? He was absolutely wrong about the tonsillectomy debate and you have pulled an abstract dealing with patients whom have on tonsil larger than another...generally tonsillectomy is not done in this situation. But it is still very necessary in others...there is not debate about tonsillectomy indications there is rock hard solid evidence based medical research that the majority of otolaryngologists follow. So with all do respect....stop acting like you know what you are talking about because you, like Obama, do not know! see below from the American Academy of Otolaryngology.
Thanks,
A disturbed ENT doc
Facts on Tonsillectomy
•In the United States, the number of tonsillectomies has actually declined significantly and progressively since the 1970s. The frequency with which tonsillectomy is performed varies from region to region. The variation appears to be related to differences in the medical practice of general practitioners, pediatricians, and otolaryngologists, in the management of recurrent tonsillitis and other conditions affecting the upper airway.
•30 years ago, approximately 90% of tonsillectomies in children were done for recurrent infection; now it is about 20% for infection and 80% for obstructive sleep problems (OSA).
•The “gold standard” for the diagnosis and quantification of OSA is full-night polysomnography, or sleep study. However, polysomnography is expensive, time-consuming, and often unavailable. Consequently, most otolaryngologists will perform an adenotonsillectomy (T&A) based on a strong clinical history and parental observation in a child with chronically enlarged adenoids and tonsils.
•Extensive data shows the negative effects of OSA in children on behavior, school performance, and bed-wetting. Improvement for such behaviors following tonsillectomy is very well documented.
•Tonsillectomy for recurrent tonsillitis is effective at significantly reducing the number and severity of sore throats in children who are severely affected. There is also anecdotal evidence that some children’s quality of life is transformed by the surgery. This may be caused by a combination of factors that include the tendency of the frequency of recurrent sore throats to resolve over time and the elimination of a source of infection and of obstructive symptoms. These conclusions were published in “TO TREAT: Tonsillitis Outcomes – Toward Reaching Evidence in Adults and Tots,” a January 2008 supplement to the journal Otolaryngology-Head and Neck Surgery.
•Tonsillectomy alone is performed infrequently in children younger than 1 year old, whereas adenoidectomy alone is performed infrequently in individuals older than 14. The rate of adenoidectomy is about 1.5 times as high in boys as in girls, while the rate of tonsillectomy is almost twice as high in girls than in boys.
•On financial incentives favoring surgical intervention: Tonsillectomy reimbursement ranges from approximately $180-$300 across all payers. For example: Medicaid reimbursement to the surgeon for performing the procedure within the state of Virginia is currently $200, and this includes all the follow-up care for 90 days following the procedure. Some payers base their fee schedules on a percentage of the Medicare payment. Out of this payment, the physician must pay significant malpractice insurance costs, as well as overhead costs for the practice, including staff salaries and benefits, and utilities.
Our Activities for Quality Patient Care
The AAO-HNS is an approved collaborator of the National Institutes of Health (NIH) Roadmap for Medical Research, PROMIS (Patient-Reported Outcomes Measurement Information System), an initiative to develop new ways to measure patient-reported outcomes (PROs). Such outcomes as pain, fatigue, physical functioning, emotional distress, and social role participation have a major impact on quality of life across a variety of chronic diseases. Clinical measures of health outcomes, such as x-rays and lab tests, may have minimal relevance to the day-to-day functioning of patients with chronic diseases. Often, the best way patients can judge the effectiveness of treatments is by changes in their symptoms. The goal of PROMIS is to improve the reporting and quantification of changes in PROs. (http://www.nihroadmap.nih.gov/about.asp)
Chronic conditions in otolaryngology require the same “whole patient” approach as noted in the NIH Roadmap. Conditions such as recurrent sore throat and infection, chronic sinusitis, sleep apnea, and recurrent ear infections, to name a few, have additional impacts on quality of life beyond clinically measured symptoms. The Academy supports an approach to physician-patient partnered decision-making that incorporates an evaluation of the patient’s overall health status, not just clinical measures, when making decisions on treatment. The Academy’s outcomes research network – BEST ENT – has published numerous studies related to quality of life for specific conditions. (http://www.entnet.org/educationandresearch/research.cfm)
Summary
Otolaryngology, like much of the surgery workforce, is facing significant manpower shortages in the coming years. We will deal with an expanding and aging population, younger physicians who value a manageable lifestyle with reasonable time commitments, and concern about the enormous debt that medical students incur. Appropriate physician reimbursement, relief from indebtedness from the costs of medical education, and tort reform are required if we are to attract the best physicians to take care of the health needs of the country in the years ahead.
This information has been developed by the AAO-HNS with the American Society of Pediatric Otolaryngology (ASPO) to achieve quality patient care by actively participating in the healthcare reform process. The decision to perform a tonsillectomy should be based on a physician-patient partnered approach and evaluation of the patient’s overall health status.
We clearly need a debate about healthcare reform, and to provide a clear and affordable model for healthcare in the years ahead. However, it is critical that this debate revolves around appropriate understanding of the issues, accurate information on the reasons for rising healthcare costs, and a consensus about the level of healthcare funding, as well as public understanding of future expectations.
References:
1.The average Medicare payment for 2009 (Federal Register, Vol. 73, No 224, Wednesday, November 19, 2008/Rules and Regulations. The 2009 Physician Reimbursement Conversion Factor = $36.0666; Federal Register/page 697726) for Tonsillectomy & Adenoidectomy, under age 12 (Surgeon CPT Code = 42820) is $270 and also includes 90 days of postoperative follow-up. Reimbursement for Tonsillectomy alone, under age 12 (Surgeon CPT Code = 42825) is $242. In the commercial payer realm, the reimbursement varies, but is not markedly higher. With the pre-authorization requirements and 90-day all-included global periods typically associated with tonsillectomy, the procedure does not yield a much greater return for surgical versus medical management of a patient. The decision to perform a tonsillectomy should be based on a physician-patient partnered approach and evaluation of the patient’s overall health status.
2.Derkay, CS. Pediatric otolaryngology procedures in the US: 1977-1987. Int J Pediatr Otolaryngology 1993;25:1-12.
3.Ross, AT, Kazahaya, K, Tom, LW. Revisiting outpatient tonsillectomy in young children. Otolaryngol Head Neck Surg 2003;128:326-31.
4.Bloor, MJ, Venters, GA, Samphier, ML. Geographical variation in the incidence of operations on the tonsils and adenoids: an epi demiological and sociological investigation. Part I. J Laryngol Otol 92:791, 1978.
5.Glover, JA. The incidence of tonsillectomy in school children. International J Edpidemiology 2008; 37 (1): 9-19.
6.McPherson, K, Wennberg, JE, Hovind, OB, et al. Small-area varia tions in the use of common surgical procedures: an international comparison of New England,
7.Clinical indicators tonsillectomy, adenoidectomy, adenotonsillectomy. Am Acad Otolaryngol Head Neck Surg. http://entnet.org/practice/products/indicators/tonsillectomy.html. Accessed August 17,2006.
8.TO TREAT (Tonsillitis Outcomes – Toward Reaching Evidence in Adults and Tots) Otolaryngol Head Neck Surg 2008; 138, S
9.Goldstein, N, Stewart, M, Hannley, M, et al. Quality of life after tonsillectomy in children with recurrent tonsillitis. Otolaryngol Head Neck Surg 2008; 138, S 9-S16
Saw this one coming. Agree with the sentiment as well, but I'm on the fence about whether Obama should weigh-in on the tonsillectomy issue. I think incentives are subtle things that we don't always consciously process. And, to some extent, I feel we're becoming victimized by hyper-specialization in our society. It's that old: If all you have is a hammer...argument. If all you have is a hammer, you're actually incentivized (or, more accurately, "encouraged") to treat everything as a nail. So, in my opinion, he's not far off base there.
Having dealt with a persistent knee problem since childhood, I've had specialist after specialist examine the knee, prescribe anti-inflammatories, and send me on my way. It wasn't until a general sports medicine physician finally put all the pieces of my various injuries together that I found out I had an IT band problem that just flared up most in the knee. Now, I do certain exercises that actually prevent the inflammation from happening in the first place. So much unnecessary time, money, and pain from a simple inability to think holistically about the problem. Of course, this is all anecdotal, and I know tragically little about physiology and medicine, so I'll shut up now.
Slag,
I agree that the incentives are subtle things that we don't always process. That is why, instead of beginning with health insurance reform, I wish the President had used his political capital to direct actual health care reform. Change the fee for procedure basis of compensation. He has the perfect vehicle for this sort of change: Medicare/aid. The Dartmouth Study he used as a means to begin the debate about health care reform demonstrated health care expenditure disparities as high as 30% in different regions with no discernible difference in health care outcomes, controlling for variables. This is something that needs to be studied and changed. A surgeon debating over a tonsillectomy (for example) does not take into account who is paying the bills, whether it be the government or private insurance. His focus will be on the patient, but there's also that slim chance he might be pushed in one direction by compensation practices.
In point of fact, if President Obama had followed the impetus of comments by Dr. Atul Gawande and the Dartmouth Study along the lines of a salaried group of physicians along the lines of a Mayo Clinic model, which has been successfully replicated in many places, specialists would meet in a peer review session, typically with a primary care physician, and they may have solved your IT problem that much sooner.
I believe we need to move toward insurance for everyone in this country, but reforming insurance before reforming health care is not only futile, but IMO fiscally dangerous.
I read through the transcript, and they are right that Obama attributed the cost of an amputation for a diabetic at $30,000 to $50,000. But he did not say (exactly) that the surgeon would receive $30,000 to $50,000 dollars for the procedure.
"All I'm saying is let's take the example of something like diabetes, one of --- a disease that's skyrocketing, partly because of obesity, partly because it's not treated as effectively as it could be. Right now if we paid a family -- if a family care physician works with his or her patient to help them lose weight, modify diet, monitors whether they're taking their medications in a timely fashion, they might get reimbursed a pittance. But if that same diabetic ends up getting their foot amputated, that's $30,000, $40,000, $50,000 -- immediately the surgeon is reimbursed. Well, why not make sure that we're also reimbursing the care that prevents the amputation, right? That will save us money."
I think Obama misspoke, and obviously his remarks should be clarified (and the figures corrected, if need be). However, if you look at the context, and you look at the "facts" (interesting how the surgeons association picked the higher figure), the overall cost does turn out to be in the range that Obama indicated, which is about $38,000, according to the Amputee Coalition of America.
Surgeons cut. That's their job. They are paid extremely well for that. They will recommend cutting as they see fit. They aren't interested in prevention. That's someone else's job. It makes no sense to pay $38,000 for any service if preventative care can accomplish the same thing, more cheaply.
More ammunition for the crazies. If anyone misspoke, it's the surgeon's association.
The reason why patients with familial adenomatous polyposis have their colons removed at an early age is to prevent colon cancer. The reason why women with lobular carcinoma in situ have bilateral PROPHYLACTIC mastectomies is to prevent breast cancer. The reason why morbidly obese patients seek gastric bypass is to prevent all of the long term sequelae of obesity. The reason why diabetics have femoral-popliteal bypasses is to prevent amputations. Making a statement that a surgeon is not interested in prevention shows complete ignorance.
Saying that we should improve preventive medicine in our country does not help the patient who needs an amputation today due to osteomyelitis.
Not to mention that preventative care should be done based on outcomes, not based on money. If we start basing it on money, do we only perform the preventative measures that actually save money? A lot don't:
http://content.nejm.org/cgi/content/full/358/7/661
Preventative medicine is tossed around way to cavalierly, as if it will save the country so much money if only we practiced preventative medicine. This is way too general and uninformed a statement for anyone serious in health care reform to make.
Also, his sentence definitely implied that surgeons walk in, cut, and pick up their huge check on the way out, while the poor GP takes the bus home after begging for change. While I will certainly agree that there are some places where the fee for service system has created some perverse benefits, and GP's are under compensated, there are ways to address that (see my post in a thread above) that do not directly attack surgeons.
Correct me if I'm wrong, but Obama didn't mention medicare's prices. The surgeon association did. They did that to try to exaggerate their claim that they aren't paid enough, simply because they do medicare procedures. It's a load of hogwash. Next time Mark, instead of breathlessly acting like a stenographer, it would be better to look at the quote and figure out why the association said that. I don't mean to tell you to do your job, but stenography is becoming very popular in the news business. I would hate to see you fall in that claptrap.
The quote from Obama:
"If a family care physician works with his or her patient to help them lose weight, modify diet, monitors whether they're taking their medications in a timely fashion, they might get reimbursed a pittance. But if that same diabetic ends up getting their foot amputated, that's 30,000, 40, $50,000 immediately the surgeon is reimbursed."
Or so says a stenographer, I guess.
OMG ... I am so reporting you to Reichsmarshall Douglass for quoting Obama. That's a fishy tactic.
Obama is, let's face it, a poor salesman for health care reform. He lies too often about it, so he's lost the trust of the American people on the issue and without trust, he can't close the deal.
Not one American believes that their doctors are looking at Medicare fee schedules before deciding on their treatment - because that just doesn't happen. Lawyers make sure that the quality of care in this country is top-notch or doctors get sued. That's why Americans don't support tort reform in this area. We want our doctors laser-focused on giving us the best care possible - or else. And they do.
Obama lied when he accused doctors of performing unnecessary tonsilectomies. He lied when he said AARP has endorsed his plan. And he lied when he claimed doctors are cutting patients legs off just to get $50,000 reimbursements. He lied when he claimed he has never supported a single-payer model.
The longer the debate goes on, the more lies pile up and the fewer people give Obama the benefit of the doubt any more.
It's best to just quote him, directly, far and wide.
He was right about the tonsillectimy thing, though. Here's a random abstract on the subject:
No he wasn't. The incidence of tumors in children's tonsils is so low as to be nonexistent. This isn't why tonsillectomies are done. Also, the incidence of tonsillectomies is far lower today because of better pharmaceutical treatment and understanding of the pathology. In addition, the people who treat patients for enlarged tonsils are not the surgeons...the patient is referred to a surgeon after medical treatment fails. What a doc gets paid for to do a tonsillectomy, which has severe potential complications from anatomy, including injury to one of the major arteries to the brain, is ridiculously low.
"Surgeons cut. That's their job. They are paid extremely well for that. They will recommend cutting as they see fit. They aren't interested in prevention. That's someone else's job. It makes no sense to pay $38,000 for any service if preventative care can accomplish the same thing, more cheaply. "
That is true...but they don't go trolling to cut off feet. Moreover, Obama made ridiculous ancillary statements leading up to this most ridiculous assertion. How is the government health care going to force people to take care of themselves...watch diet, give themselves injections, quit smoking, etc.
Preventive care is a misnomer, especially with metabolic diseases like diabetes. All you can hope to do is postpone the inevitable...which will, in many cases, mean peripheral vascular disease leading to amputation. Instead of having it at 50, maybe you put off the end stage until 60. But with these diseases, no matter what one does to control them, there comes a time where the complications occur and more expensive treatment is needed.
Unless, of course, you've outlived your value to society and Obamabots decide you aren't worth the trouble.
He was right about the tonsillectimy thing, though. Here's a random abstract on the subject:
No he wasn't. The incidence of tumors in children's tonsils is so low as to be nonexistent. This isn't why tonsillectomies are done. Also, the incidence of tonsillectomies is far lower today because of better pharmaceutical treatment and understanding of the pathology. In addition, the people who treat patients for enlarged tonsils are not the surgeons...the patient is referred to a surgeon after medical treatment fails. What a doc gets paid for to do a tonsillectomy, which has severe potential complications from anatomy, including injury to one of the major arteries to the brain, is ridiculously low.
"Surgeons cut. That's their job. They are paid extremely well for that. They will recommend cutting as they see fit. They aren't interested in prevention. That's someone else's job. It makes no sense to pay $38,000 for any service if preventative care can accomplish the same thing, more cheaply. "
That is true...but they don't go trolling to cut off feet. Moreover, Obama made ridiculous ancillary statements leading up to this most ridiculous assertion. How is the government health care going to force people to take care of themselves...watch diet, give themselves injections, quit smoking, etc.
Preventive care is a misnomer, especially with metabolic diseases like diabetes. All you can hope to do is postpone the inevitable...which will, in many cases, mean peripheral vascular disease leading to amputation. Instead of having it at 50, maybe you put off the end stage until 60. But with these diseases, no matter what one does to control them, there comes a time where the complications occur and more expensive treatment is needed.
Unless, of course, you've outlived your value to society and Obamabots decide you aren't worth the trouble.
I am a recently retired Orthopedic Surgeon from Massacusetts. Granted our state has a low level of reimbursement for surgical procedures. Nonetheless, when I heard our President assert that some surgeon would be "reimbursed $30,000 to $40,000" for performing a leg amputation, I sputtered to my wife: "How about $680."
One has to understand that most surgeons are deeply saddened about doing any type of amputation. Unfortunately, the President's construct of such a situation completely misrepresents the attitude of any surgeon I know. To suggest that there is a monetary calculation in a patient's ending up with an amputation is absolutely insulting.
More inportantly, it suggests a total lack of understanding of the way medicine works. This lack of understanding has been manifested in several medical discussions by the President.
He seems to believe that cost considerations clearly trump specific evaluation as to an individual patient's ability to benefit from a contemplated procedure. One can only wonder at the mandate under which his proposed medical panels will be operating.
"Death panels" may seem an exaggeration, but who knows the limits that medical rationing will impose. This uncertainty comes across to people, and is a major source of the massive fear that has overtaken so many Americans as they contemplate the nature of their medical care in our brave new world.
Bill Davis says above: "Surgeons cut. That's their job. They are paid extremely well for that. They will recommend cutting as they see fit. They aren't interested in prevention. That's someone else's job. It makes no sense to pay $38,000 for any service if preventative care can accomplish the same thing, more cheaply. "
Like President Obama, Mr. Davis, you are wrong. The American College of Surgeons' statement is accurate. $740 to $1,140 is the usual rate of remuneration for the surgeon. The surgeon can hardly be held responsible for what occurred before he came on the scene.
It seems to me that the only reason surgeons are compensated well is because they work 60-80 hour workweeks, often beginning at 530 and ending at 7 or 8 PM at least 5 days a week.
I think the only time a money question consciously comes to a physicians mind is when he thinks: "This test is expensive and probably unnecessary, but if I don't do it, will I get sued later?" And yet Obama flatly refuses to even entertain restrictions on malpractice suits.
None of these comments, while some are instructive and clear-thinking, address the issue of why on earth the President of the United States is creating public policy recommendations and pressing for legislation regarding the practices of any medical specialty. That seems to me to be the basic question we should consider. Political interpretations of complicated medical diagnoses and treatments are at a minimum suspect, and yet we are about to take massively intrusive government actions based upon them. We will all come to rue the day we allowed our representative system to undertake them, irrespective of contentious matters regarding competence and motive.
In addition, it strikes me that the man is a demonstrated and serial liar. One or two misstatements from his high position can perhaps be overlooked as unfortunate errors. But Mr. Obama makes them repeatedly: The lie about Caterpillar's hiring practices some months ago, the lie yesterday about AARP supporting his program, the lies about tonsillectomies and amputations, just to cite a few examples. Furthermore, neither he nor the congress have any competence to be judging medical matters.
Agree with above.
Diabetes control is easier said than done. People rely on doctors to prescribe all the right medications, all the right treatments, and all the right preventative measures. Guess what? No matter how good a doctor is, if a patient does not follow these guidelines, the best preventive measures are lost. The patients who are non-compliant are the ones who generally end up getting these types of complications. The surgeon is only called upon when medical therapy fails.
Health and medical care is complex and multifactorial. Perhaps Obama should tell the American people to stop eating candy bars, exercise more, work less/sleep more, and turn off their satellite TV's rather than put all the responsibility on doctors doing their best to control an epidemic. Maybe the government should regulate the food industry before trying to regulate the medical field. Maybe healthy food should be less expensive. Maybe middle schools and high schools around the country should let kids have gym class and play dodgeball. Maybe we should take siestas in the middle of the day and have workplace massages. Maybe TV stations should stop putting anorexics in commercials. Maybe cigarettes should be illegal. Doesn't Obama smoke cigarettes? Let's see what his opinion is when he's the one who needs an amputation. Let's see if he feels his surgeon is trying make a quick buck.
I don't understand global economics so I would not feel comfortable managing the country's financial affairs. The reverse is true. I am not comfortable with people in business suits telling people in white coats and scrubs what to do.
If Obama were a surgeon, he would have done what he accused the surgeons doing.
I had my tonsil out when I was six. Alternative: 104 fever every couple of weeks, and seizures. Even then, the surgeon was reluctant because the tonsil is our first line of defense against infections. A surgeon has to be very unethical to do the procedure for a couple of bucks.
I have my colonoscopy every ten years, the surgeon charges $1200 fee, is paid $400 by Cigna. I also have annual physical, Quest diagnostics charges me $35 for blood test. I am entitled to a free annual physical, so I don't pay Quest, Cigna is supposed to. Cigna pays them $0. I don't know what arrangement is made between Cigna and the providers, but seems the providers don't make a whole lot on preventive care.
The so-called reform bill also discourages regular tests to save cost.
Don't forget Obama never mentions those malpractice lawsuits. As a matter of fact, the doctors are supposed to give up about $18,000 earning per year, but can still be sued frivolously. An obgyn pays $120,000 a year malpractice insurance premium in Chicago. A dentist pays a stagger premium: a premium to cover current year's patients, an additional to cover last year's, another to cover prior year's ... in case the patients he treated 10 years ago sue him. Neither the ob-gyn, nor the dentist ever had a law suit.
By the way, Obama's administration has just signed an agreement with the Chinese. We'll do quality control for them, they'll supply us with "cheap" safe drugs. A 300 billion dollars generic drug industry will be moved to China, courtesy of Uncle Sam. Don't be surprised if our science grads can't get a job.
What the hell do we produce anyway? The world's top two oil drilling services companies: Noble and Transocean moved to Switzerland from Houston to avoid high taxes. Another oil producer moved to France. France, imagine that! It's funny the rich don't stay to be soaked.
Some questions: why are all Congressmen and Senators multi-millionaires? Why don't they pay FICA and medicare? The amendment requiring Congress members and staffers to use Obamacare passed the Senate by one vote, and the amendment is unlikely to appear in the final bill. Why is Obamacare good enough for us, not good enough for them?
I think it's pretty clear President Obama meant that that total cost of an amputation is more than $30K. He should correct his statement and people of good will should accept his larger point about ensuring we pay for effective preventive care. That there are few people of good will engaged in the debate seems clear by now.
ic writes: "It's funny the rich don't stay to be soaked."
And freedom isn't free. Perhaps if we minded our own business, stopped invading other countries, and stopped guaranteeing the defense of our so-called allies, we could take better care of our own.
So yes, let's stop paying taxes. Bring all the troops home first.
As for your friends at Transocean,
"HOUSTON: Transocean Inc.'s board of directors has unanimously approved moving the place of incorporation of its group holding company from the Cayman Islands to Switzerland. Transocean's shareholders will be asked to vote in favor of the proposal at a shareholders meeting."
http://www.energycurrent.com/index.php?id=2&storyid=13632
"Several major corporations are trading white sand beaches for alpine slopes by reincorporating from Bermuda and the Cayman Islands to Switzerland. Such companies as ACE, Foster Wheeler, Transocean, Tyco International, Weatherford International, and Noble have presented or will present to shareholders proposals to reincorporate in Switzerland, making the move from one tax haven to another. Of primary interest to companies is Switzerland's tax structure, which offers essentially the same tax benefits as its tropical brethren. Although Switzerland does have a corporate income tax whereas Bermuda does not, the Alpine nation does not tax the profits made by foreign subsidiaries of companies. Tyco, Foster Wheeler, and other firms are creating holding companies in Switzerland that "own" their global operations without being taxed on the profits from these international businesses. The largest potential benefit of reincorporation in Switzerland, however, is the nation's long-standing and stable U.S. tax treaty, which consultants and advisers expect to protect these corporations from any potential tax-haven legislation enacted under the Obama administration. While the companies won't publicly acknowledge this anticipatory forum-shopping, the tax treaty should provide a stable tax environment for these companies."
http://www.riskmetrics.com/governance_weekly/2009/333
Right, doctors never overcharge. All the lies being propagated by anti-reform blowhards and Obama exaggerates a price and it's a major crime.
Maybe he read some of the examples in the NYT article,"Insurers' Survey Points to...," of the ridiculous charges sent to insurers when patients are out of network! For example:
"Patients who receive unexpected bills may not know what to do. That happened to Charles Bacchi’s mother. Mr. Bacchi, executive vice president of the California Association of Health Plans, said his mother was admitted to a hospital that had just dropped its association with her insurer. Mr. Bacchi’s mother, who spent less than a week in the hospital, received a bill for nearly $90,000 and was told that her plan would pay only a small part of it. Mr. Bacchi said she was terrified and hid the bill. “She thought the entire family savings would go up in smoke,” Mr. Bacchi said. When his mother finally told him about the bill, Mr. Bacchi intervened, and eventually the matter was settled by the hospital and the insurance company."
PLEASE NOTE in this example her son's profession: most people don't have a health services professional available to intervene.
(warning: soapbox)
I am a surgical resident. I graduated from a very expensive private medical school in 2006. It was the only medical school close to my family where I was accepted. Luckily for me, I received a full tuition scholarship for my undergraduate studies, otherwise my educational debt would be double what it is now. I borrowed somewhere in the vicinity of 260,000 dollars for medical school and when I get it all paid back, I will have paid back almost 500,000 dollars.
My wife's educational and financial situation is the same. My wife and I are the first doctors in our families. We are both from middle class families.
When I finish residency and fellowship, and finally start earning enough money to start paying back my loans, I will be 37 years old. I've buried the prime years of my life in books and at work instead of at family vacations and nights out with friends. I hardly get to spend anytime with my wife or family. Officially I am not allowed to work over 80 hours a week, but when there is a patient in need or if I am learning something that will help me take better care of my patients, I ignore my work hour restrictions. I do this because surgery is my passion, my calling. I can't imagine doing anything else with my life.
When I go to work everyday, my mentors teach me how to take care of patients before, during, and after surgery. I learn about diseases and their cures. What they don't teach me is how to bill a patient or an insurance company. They don't teach me how to run a business or what to do when I get named in a lawsuit. I don't have lectures about malpractice insurance or hospital economics. And yet, this is the climate I will need to navigate when I graduate.
Mr Obama, do you want an economic stimulus package idea? Here's one: pay back my student loans, pay back my wife's student loans, pay back the student loans of everyone in my graduating medical school class, pay back the student loans of all of the young professionals out there who are starting out in their careers with seemingly insurmountable debt. We are citizens who will buy cars and pay off car loans, buy houses and pay off mortgages, rent office space for our small businesses, and at the same time, provide public service. A doctor starting a practice needs to hire medical assistants, nurses, physician's assistants, nurse practitioners, phlebotomists, secretaries, transcriptionists, medical language interpreters, custodial staff, information technologists, and more. The same goes for lawyers, dentists, veterinarians, architects, engineers, and all other technologists. Economic stimulus should focus on building infrastructure rather than giving meaningless little tax breaks which people use to buy ipods.
How does Ambinder find this press release "amusing"?!
It's -funny- that the president is lying to us?
I agree with kazoolist. Why is this press release amusing? In fact, you should be printing more of these! I don't think Obama is 'lying' but his WH aides are dragging him through the mud with these types of things. All they had to do was call the "College of Surgeons" and fact-check.
As a surgeon, I find it disturbing when the President wades into the complexities of medical care and misrepresents the issues. From my review of the transcript provided by the other commenters, he states that a family care physician is reimbursed a pittance, but suggests that a surgeon is reimbursed the $30k-50k. Now, I guess it's possible that he misspoke, confusing hospital vs. surgeon reimbursement. But I would hope that the President should be able to avoid these mistakes. Perhaps, he (or his speechwriters) should speak with actual practicing surgeons/physicians before he makes these unfortunate comments.
I agree that, in the present billing and coding system, primary care providers get the short stick, but to make a grossly exaggerated comparison with surgeons doesn't help his cause, at least from the medical community. The first part of Obama's comment is key: getting patients to lose weight, modify diet, and take their medications. I'm not sure that increasing reimbursement to primary care providers will change much. At least in my area, most PCPs are frustrated with patient non-compliance, especially when it comes to obesity and diabetes. As a specialist, I'm all for preventive care; I've seen enough high-risk obese, diabetic patients who require surgery; I would much rather operate on only healthy, low-risk patients who need surgery. This emphasis on physician reimbursement and primary care vs. specialist care as an argument for increasing preventive care seems misplaced. The average American, of which 2/3 are overweight and 1/3 are obese, needs to be held more accountable.
Here's some food for thought...
As stated above, surgeons do not go trolling for amputations of diabetic legs. I would say that our mindset is to save the leg at all cost, and that amputation is the procedure of last resort. We are quite aware of the functional and psychological issues after amputation. Reimbursement really is not a factor, especially when amputation is a medical necessity. For some surgeons, performing an amputation can be associated with a sense of failure because he/she tried everything to save the leg. For those who think that surgeons are paid to cut, perhaps we should be more liberal in proceeding to amputation. There's a lot of cost involved with trying to save a leg (wound care, office visits, vascular studies, angioplasty/stents, surgical revascularization). I'm sure the health care system could save a lot of money if we could identify those non-compliant patients (smokers, poorly controlled diabetes) with severe disease, and just proceed directly to amputation. Vascular surgery is not part my current practice, but I have seen some truly heroic, but futile, attempts at limb salvage, where aggregate cost easily extended into the six-figures.
Obama admitted during the campaign (but now blatantly lies about it) that he supports a single payer system, i.e. Socialized Medicine; and, his "Government Option" is designed to force private insurers out of the market in order to achieve precisely that goal. As Obama said: "I don't think we're going to be able to eliminate employer coverage immediately. There's going to be potentially some transition process..." Barney Frank then unashamedly admitted that Obama's "Public Option" was simply a Trojan Horse for surreptitiously introducing full blown Socialized Medicine. The American people have astutely spoken loud and clear that Socialized Medicine is anathema; but, Obama's Marxist psyche prohibits him from accepting free market reforms which should begin with shutting down illegal immigration and Tort Reform, both of which Obama unconditionally rejects. Obama's ACORN is busily registering illegals; and, Trial Lawyers are among his principal campaign contributors. But the most insidious part of Obama's plan is the coming bureaucratic denial of life saving procedures for the elderly. As Obama says: "Take an aspirin" and just wait to die. ( Pg 30: SEC. 123. HEALTH BENEFITS ADVISORY COMMITTEE of HC bill - THERE WILL BE A GOVERNMENT COMMITTEE that decides what treatments/benefits you get. AND, PG 430: SEC. 1233. ADVANCE CARE PLANNING CONSULTATION Lines 11-15 The Government will decide what level of treatment you will have at end of life.) The elderly should revolt over Obama's health care proposals. He learned from his wife Michelle that considerable sums of health care funds could be saved by the practice of "patient dumping" which Michelle employed in Chicago. Facts that are precisely why Health Care legislation, that HAD TO BE DONE BY YESTERDAY, does not take effect until 2013, i.e. AFTER the next presidential election when voters will then be blindsided by a pending disaster. And, just remember that Obama and his Congressional colleagues have EXEMPTED themselves from compliance with their own proposed health care debacle. Greg Neubeck
I am 55 years of age and was diagnosed with Childhood Onset Diabetes at UCLA Medical Center (Los Angeles, CA) June 20, 1959. I have been dealing with this disease over 50 years. I have always been daily injecting 2 different types of insulin, one, at least 4 times every 24 hours. My blood sugar values very frequently swung outside of the normal range, wildly up and down, never staying at any particular level. After 26 years of evaluating those, I put myself on intensive insulin therapy. (This has not been the reason for blood sugar fluctuations, as I’d been experiencing the prior 26 years, like a few MD’s tried to make me believe.)
I have never developed kidney disease, heart failure, blindness, nor have I had amputation. I have no serious diabetic complications. I am evidence that the most wildly fluctuating blood sugars, over an extended period of time, may not cause those problems, even after 50 years.
On the opposing side, my very dear friend, and previous employer, managed her blood sugars extremely well for the initial ten years after her Childhood Onset Diabetes diagnosis. Then, within a year, she experienced severe complications causing her to have 4 organ transplants. She is evidence that well-managed blood sugars, over an extended period of time, may not prohibit severe complications.