Doctor's say "NO" to Obamacare!

Sally Pipes, Contributor (I cover health policy as President of the Pacific Research Institute )

Op/Ed

Doctors Say Obamacare Is No Remedy for U.S. Health Woes

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+ Comment now America’s doctors have conducted a full examination of the president’s health reform law — and their diagnosis of its effects on our healthcare system isn’t good.

Nearly two-thirds of doctors expect the quality of care in this country to decline, according to a new survey from consulting giant Deloitte. Just 27 percent think that the law will lower costs. And nearly seven of every 10 doctors believe that medicine is no longer attractive to America’s “best and brightest.”

Few people know more about our healthcare system than doctors working on the frontlines. Policymakers should pay heed to their indictment of Obamacare and revisit the disastrous law.

President Obama promised that his reform package would begin to stymie the out-of-control growth in the cost of American health care. He pledged $2,500 in health insurance savings for the typical American family.

But doctors don’t buy it. Only one quarter feel that Obamacare will reduce health insurance costs for consumers. Nine out of ten posit that insurers will raise premiums for employers and individuals.

They have good reason to doubt Obamacare’s cost-cutting potential. Healthcare spending is expected to reach $2.7 trillion this year — or about $1 of every $6 spent in our economy. By 2020, health spending will account for a full fifth of America’s GDP.

That increase is in large part thanks to Obamacare. Instead of relieving high insurance premiums, the nonpartisan Congressional Budget Office estimates that American families in the non-group market will see their premiums rise $2,100.

They’re already trending higher. According to the Kaiser Family Foundation, average family premiums in 2011 topped $15,000 — a 9 percent increase from 2010. Prior to Obamacare’s passage — from 2009 to 2010 — premiums went up just 3 percent.

In April 2010, Richard Foster, the Chief Actuary of the Centers for Medicare and Medicaid Services (CMS), concluded that American spending on health care through 2019 would be $311 billion higher than if the law had never passed.

Even with all that additional money flowing through the system, doctors don’t think that the quality of care will improve. Half of all doctors believe that access to care will diminish because of hospital closures prompted by health reform.

Further, nearly 70 percent of doctors believe that long wait times will plague emergency rooms. A full 83 percent of physicians foresee increased wait times for primary care appointments.

That’s in large part because Obamacare is expected to extend government-subsidized insurance coverage to many folks — even as the supply of providers remains relatively constant.

The United States already faces a shortage of primary-care doctors. Medical schools today produce one such physician for every two our country needs. By 2019, the American Academy of Family Physicians warns that the United States will be short 40,000 doctors.

Expanding insurance coverage to millions more Americans won’t do much good if they can’t get doctor’s appointments. Physicians believe that their ability to provide quality care will be further strained by the law’s attempt to change the way they’re paid — from a fee-for-service basis to a vaguely defined system of paying doctors based on patient health and outcomes.

Nine out of ten physicians fear they will receive inadequate payments and endure higher administrative costs. Fewer than a quarter of doctors expect their paperwork requirements to ease up. Time spent wading though paperwork is also time no longer available for actually practicing medicine.

American doctors’ negative view of Obamacare is telling. Proponents of the law may claim that their griping is misplaced, but as Paul Keckley, Ph.D., the lead author of the report explains, “Understanding the view of the physician is fundamental to any attempt to change the health care model.”

In other words, if physicians aren’t on board with Obamacare, it won’t work. A law that hinders the practice of medicine, obstructs access to care, and costs Americans more is clearly not the right remedy for what ails us.

Sally C. Pipes is President, CEO, and Taube Fellow in Health Care Studies at the Pacific Research Institute. Her next book — The Pipes Plan: The Top Ten Ways to Dismantle and Replace Obamacare (Regnery) — will be released in January 2012.

ObamaCare's Very Bad Year!

Paul Connor, The Daily Caller.

2011 was supposed to be a bad year for President Obama’s health care law, with House Republicans taking aim and federal lawsuits snaking their way through the judiciary. And although the House of Representatives has had limited success in dismantling the overhaul, key portions began to unravel all by themselves.

Here’s a look at the Patient Protection and Affordable Care Act’s year in review.

– Jan. 14: Kansas announces its intention to become the 26th state to file suit against the federal government to stop implementation of the health care overhaul.

– Jan. 19: The House of Representatives votes to repeal the health care law.

– Jan. 26: Illinois-based pharmaceutical company Abbott Labs cuts 1,900 jobs “in response to changes in the health-care industry, including U.S. health-care reform and the challenging regulatory environment.”

– Jan. 31: A second federal district judge rules that the law is unconstitutional.

– Feb. 2: All 47 Republican senators vote to repeal the Affordable Care Act, but the measure fails.

– Feb. 16: Health and Human Services Secretary Kathleen Sebelius testifies before the Senate Finance Committee and admits that the CLASS Act, a key portion of the law that was touted as a $70 billion savings, is “totally unsustainable.” But not to worry: Sebelius says her department has the authority to rework the legislation to make CLASS tenable.

– Feb. 18: The House votes to block federal funding to implement the Affordable Care Act. The Congressional Budget Office also estimates that repealing the law would add $210 billion to the combined federal deficits from 2012 to 2021.

– Feb. 22: A federal judge tosses a lawsuit claiming that the Affordable Care Act violates the liberties of those who choose to rely on God to protect and heal them instead of buying health insurance.

– March 3: The House votes to end an unpopular tax paperwork-filing requirement for businesses tucked into the health care law.

– March 23: The law turns one year old. On the same day, the House Committee on Energy and Commerce finds that the temporary Early Retirement Reinsurance Program will spend its allotted $5 billion far earlier than its Jan. 1, 2014 expiration date.

– March 30: The CBO estimates that health care reform will cost $1.1 trillion, an increase of $90 billion from its February estimate.

– May 17: The Daily Caller reports that 20 percent of new waivers from the law have gone to gourmet restaurants, nightclubs and fancy hotels in former House Speaker Nancy Pelosi’s district.

– June 8: A McKinsey & Company survey of over 1,300 private sector employers found that 30 percent of employers would definitely or probably stop offering insurance to their employees after the law is implemented in 2014.

– June 18: HHS announces that it is axing waivers from the law.

– June 21: A glitch in the law, discovered after Obama signed it, would allow middle-class Americans to get subsidized health care intended for poor people, the Associated Press reports. Medicare’s chief actuary says the policy “doesn’t make sense.”

– June 29: In the face of a constitutional challenge, the Sixth Circuit Court of Appeals rules in favor of the law.

– July 18: An Employment Policies Institute report finds that the Affordable Care Act would incentivize employees to switch to a government-subsidized insurance exchange even if employers were to continue their health care coverage, costing taxpayers “significant[ly].”

– July 19: The bipartisan “gang of six” puts forward a debt-reduction plan that would repeal the CLASS Act.

– Aug. 1: HHS issues a regulation requiring all group health insurance plans to cover FDA-approved “contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity.”

– Aug. 12: The Eleventh Circuit Court of Appeals rules that the law’s individual health insurance mandate is unconstitutional.

– Sept. 8: The Fourth Circuit Court of Appeals rejects a pair of challenges to the law on procedural grounds. It does not rule on the law’s constitutionality.

– Sept. 15: A bicameral Republican report accuses Democratic supporters of the health care law of recklessness for promoting the CLASS Act despite knowing that the program would eventually blow up the budget.

– Oct. 5: The signatures of about 1.6 million petitioners pressing for the repeal of the Affordable Care Act are delivered to Capitol Hill at a press conference.

– Oct. 13: A federal inspector general finds that the IRS is having trouble collecting the 10-percent federal tanning tax established by the law.

– Oct. 14: HHS completes its 19-month review of the CLASS Act, determining that “we do not have a path to move forward,” Sebelius says. CLASS remains on the books, but the administration essentially gives up on it.

– Nov. 4: Tennessee Rep. Phil Roe and 23 Republican colleagues send a letter to IRS Commissioner Douglas Shulman objecting to a new IRS rule authorizing subsidies for participants in the yet-to-be-created federal health care exchange program. They argue that the agency is seeking to rewrite legislation, something it is not allowed to do. Conservative experts say the IRS rules are covering up a glitch in the original law that provides subsidies for people enrolled in state exchanges, but not federal exchanges. Shulman does not agree with their analysis.

– Nov. 9: The National Federation of Independent Business releases a report saying that in 2012 the law’s new health insurance tax will reduce private sector jobs by between 125,000 and 249,000.

– Nov. 10: The Beckett Fund for Religious Liberty announces it is suing HHS on behalf of Belmont Abbey College, a Catholic educational institution. The lawsuit claims the Aug. 1 regulation violates the college’s teaching on contraception, sterilization and abortion.

– Nov. 14: The Supreme Court agrees to hear arguments on the Affordable Care Act.

– Nov. 16: Forty-seven percent of Americans favor repeal of the law, Gallup finds.

– Nov. 29: Massachusetts Democratic Rep. Barney Frank joins the effort to repeal the Independent Payment Advisory Board, a key portion of the law that would “recommend levels at which Medicare recipients, including seniors, can be reimbursed for health care expenses.”

– Nov. 30: The House energy committee votes to repeal the CLASS Act.

– Dec. 15: The Obama administration announces that the number of young uninsured Americans has fallen by 2.5 million, attributing it to his law’s provision permitting young adults to stay on their parents’ health care plans until age 26.

– Dec. 18: Health care experts doubt that the federal insurance exchange program will be fully operational by the Jan. 1, 2014 deadline, since many states have refused to implement the state exchange program, the Washington Post reports.

– Dec. 19: The Supreme Court announces it will hear an unprecedented week’s worth of arguments in March 2012 to determine whether the health care overhaul law is constitutional.

Medicare plans to cut reimbursements by 27% in 2012

Doctors facing 27% cut in their Medicare fees

Arizona Daily Star | Posted: Tuesday, November 29, 2011 12:00 am

WASHINGTON - Politicians of both parties outdo each other vying for the approval of seniors, but their inability to compromise on the federal budget has put Medicare in the crosshairs again.

Unless Congress acts before Jan. 1, doctors face a 27 percent cut in their fees for treating Medicare patients. That could undermine health care for millions of elderly and disabled beneficiaries.

Last year around the holidays doctors were looking at a cut of about 20 percent.

The cuts are the consequence of a 1990s budget law that failed to control spending but never got repealed. Congress passes a temporary fix each time, only to grow the size of reductions required next time around. The supercommittee's breakdown leaves the so-called "doc fix" unresolved with time running out.

A thousand miles away in Harlan, Iowa, Dr. Don Klitgaard is trying to contain his frustration.

"I don't see how primary care doctors could take anywhere near like a 27 percent pay cut and continue to function," said Klitgaard, a family physician at a local medical center. "I assume there's going to be a temporary fix, because the health care system is going to implode without it."

Medicare patients account for about 45 percent of the visits to his clinic. Klitgaard said the irony is that he and his colleagues have been making improvements, keeping closer tabs on those with chronic illnesses in the hopes of avoiding needless hospitalizations. While that can save money for Medicare, it requires considerable upfront investment from the medical practice.

"The threat of a huge cut makes it very difficult to continue down this road," said Klitgaard, adding "it's almost comical" lawmakers would let the situation get so far out of hand.

Physian's Pay may increase, Maybe!

Doctors to see slight salary increases in 2012

October 18, 2011 | Stephanie Bouchard, Associate Editor

PHILADELPHIA – Doctors can expect to see salary increases in 2012 but they’ll be smaller than those in 2011 says a physician compensation survey released this week by global consulting firm, the Hay Group. In 2011, physician salaries increased by 2.7 percent but expectations are that in 2012 they'll increase only by 2.5 percent.

The size of the salary increases is impacted by organization-specific things such as the salary increases provided to other employees, and, more importantly, reimbursements, said Jim Otto, senior principal in Hay Group’s healthcare practice. “The primary influences on these increases are likely to be flat or minimal increase in reimbursement for services rendered and flat or minimal increase in actual services rendered that result in reimbursement,” he said.

Doctors working in group-based practices are expected to see pay increases of 3.2 percent in 2012 but hospital-based doctors are only expected to see increases of 2.5 percent. More specifically, physician specialists working in hospitals may expect an increase of 2.4 percent and those in group practices may expect a 4.5 percent increase. Primary care doctors in hospitals may expect a 2.9 percent salary increase in 2012 while their peers working in group practices may expect a 3.3 percent increase.

The differences in salary increases between hospital-based and group-based doctors are likely the result of three things, Otto said: group income from ancillary services that are part of a practice’s business lines and which are not part of a hospital-employed physician’s compensation; sharing in profit after expenses for physician owners, which is also not part of a hospital-employed physician’s compensation; and employed physician increases being influenced by budget and salary increases for the other employees of the hospital.

With the demand for primary care physicians up, it’s not as surprising that they are expected to have larger salary increases than specialists in 2012. “The expected increases to primary care physicians is a reflection of the importance of their role in the healthcare reform environment – for example, accountable for integrated patient care models – the increase in reimbursement that is being paid by insurance companies and the government for primary care services, and the decreasing reimbursement for other specialists,” Otto said. “This does not mean that the pay differences that you see in the market between primary care physicians and specialists will evaporate quickly, but over time these differences are expected to shrink.”

Other findings from the physician compensation survey include:

• When determining base pay structure, 50 percent of organizations set physician pay on an individual basis, 28 percent establish formal salary ranges, 18 percent use market rates and 1 percent use step-rate progression.
• The prevalence of annual incentive plans decreased slightly among all physician participants in 2011.
• Measures for determining incentive payouts continue to be dominated by quality and patient satisfaction.

Follow HFN associate editor Stephanie Bouchard on Twitter @SBouchardHFN.

Physician Salaries - Towns and Cities; Size does matter!

How does Town Size and Population Affect Physician Salary?

By Andrea Santiago, About.com Guide

Question: How does Town Size and Population Affect Physician Salary?

A reader, who is a future physician, posed some questions about physician salary as it relates to the size of the community in terms of population. Do physicians earn more in small towns or large cities, and why?

Answer: In discussing physician compensation, the use of the term "salary" can be misleading, since many physicians are not employed, nor are they paid a base salary. Most physicians (more than 50%) are in business for themselves, owning a private practice in full or in part, as opposed to being employed by a hospital or group. Even for physicians who are employed, their compensation is controlled by many geographic, economic, and demographic factors, such as managed care and insurance reimbursements, which are set by third party organizations and government regulations.

According to the Medical Group Management Association (MGMA) which conducts extensive annual surveys and analysis of physician compensation, most physicians earn more money in communities which are well under one million in population. In many specialties, the highest earners are found in towns of 50,000 to 250,000 in size, according the the MGMA statistics.

This disparity in compensation is due to several factors:

Competition: In smaller to mid-sized communities, competition from other physicians is not as prevalent as in larger metropolitan areas, which tend to become “over-doctored” due to the tendency of doctors to flock to large cities due to family ties or perceived benefits of working in a larger city.

Reimbursements: Reimbursements from insurance companies tend to be higher in small- to mid-sized communities. Therefore, a physician in a big city and a physician in a small town could see the exact same amount and type of patients, and do the same amount of work, and each physician could be reimbursed completely different amounts based on the rates in their area, and often it’s the small-town doc that comes out ahead.

Overhead costs: Typically, costs of practicing as a physician, such as malpractice insurance, and office space, are higher in larger cities. This is because larger cities tend to be more litigious environments than smaller communities, and frequent lawsuits drive up the cost of malpractice insurance further.

Examples of high-earning physician specialties in smaller towns:

Orthopedic Surgeons These surgeons earn the most in towns of 50,000 or less, typically. For example, according to the MGMA Physician Compensation and Production Report of 2009, orthopedic surgeons in the smallest towns earn a median annual income of $502,195, and only $474,359 annually in in metro areas larger than one million people in size. Their median income decreases further in towns with a population of 250,000-1,000,000, to about $393,402.

Gastroenterologists in smaller towns (under 50,000) earn an average of $467,927. Those physicians in towns of 50,000 to 250,000 earn $452,195 on average, which is a whopping 22% more than their counterparts in major metro areas (over one million population), who earn $370,673 annually on average.

Dermatologists earn the most in towns of 50,000-250,000 with a median income of about $395,159. In major metropolitan areas, dermatologists earn about $50,000 less than that, with a median annual income of $340,317 in cities with a population over one million. In towns under 50,000 in size, derms earn $356,624, according to the MGMA 2009 Physician Compensation and Production Survey.

Cardiologists in small to mid-sized towns earn anywhere from 17% to over 25% more than those in major metro areas. Those increased earnings can equate to a difference of nearly $150,000 annually for some cardiologists in smaller communities! Interventional cardiologists see the most dramatic effects of town size on income, for example, with median earnings of $609,041 in small towns (under 50,000 people), and $462,820 in major metro areas (over one million people).

Above are just a few examples. The list goes on, but these are a few of the most dramatic examples. Not every specialty sees such a significant difference, but nearly every specialty sees a gain in compensation in smaller towns, particularly those in the lucrative range of 50,000 to 250,000 in population, which are the highest paying locations for most specialties. As an added bonus, in addition to earning more money each year, physicians in smaller communities get more for their money, obtaining additional savings and improved financial situations for doctors who practice in small or mid-sized communities.

Medicare cuts again as Super Committee (read disengaged politicians) agrees to inaction!

Super committee failure leaves Medicare pay cuts in place

Deficit panel inaction will trigger a $1.2 trillion federal spending reduction that could cut Medicare pay even more starting in 2013.

By Charles Fiegl, amednews staff. Posted Nov. 21, 2011.

Washington -- Roughly $1.2 trillion in automatic cuts over 10 years will hit federal programs, including Medicare, after lawmakers on a special 12-person bipartisan deficit reduction committee failed to develop a consensus plan.

Leaders of the Congressional Joint Select Committee on Deficit Reduction announced on Nov. 21 that they would not be able to reach an agreement on a spending cut plan by the Nov. 23 deadline set by Congress. Organized medicine had hoped the committee would strike a deal that not only met the panel's minimum goal but that also fixed the long-term physician payment problems plaguing the Medicare program. Its failure means that unless lawmakers act to change the outcome, the sustainable growth rate formula will cut physician pay by 27.4% in 2012 and by an additional amount in 2013, and the automatic spending cuts will decrease pay even further starting in 2013.

American Medical Association President Peter W. Carmel, MD, said lawmakers on the committee missed a unique opportunity to fix the SGR formula, avoid further cuts to doctors and preserve beneficiary access to care.

"The failure of the deficit committee forces our nation to continue on an unsustainable path that puts current and future generations of Americans at risk for harsh consequences," Dr. Carmel said. "Congress set up processes and procedures that could have charted a course to put our nation's fiscal house in order. The stalemate in the deficit committee will trigger robotic, across-the-board spending cuts, which will not address critical structural problems in the federal budget."

Congress had created the panel, which many dubbed the super committee, as part of an agreement to raise the federal debt ceiling in August. The Budget Control Act gave the committee the task to develop a plan to reduce budget deficits by at least $1.2 trillion between 2012 and 2021. Failing to agree on any plan would trigger 10-year spending cuts equal to $1.2 trillion starting in fiscal 2013, divided roughly equally between defense spending and nondefense spending.

The act specifically exempted Medicare patient benefits from being impacted by the automatic spending cuts, meaning that Medicare pay to health professionals would be on the chopping block. The statute does cap the amount of cuts from Medicare as a whole to 2% per year, amounting to a $123 billion decrease in program spending over the decade, according to a Sept. 12 Congressional Budget Office report.

The projected effect of the automatic cuts on physician pay is not yet known. The White House would determine proportional budgetary reductions annually, and the president then would order the necessary cuts, according to the CBO. Congress could vote to roll back some or all of the automatic reductions contained in the budget act's fail-safe mechanism, and some lawmakers indicated that they might attempt to do that for certain defense spending and other priorities. But President Obama warned Congress against trying to escape its budgetary responsibilities and the White House indicated that he would be willing to veto such legislation.

Meanwhile, the federal government avoided its latest shutdown on Nov. 18 as Obama signed legislation to keep federal agencies funded through Dec. 16. Another appropriations bill would be needed to fund the government after that date.

Millions lose Employer-Sponsored Healthcare (Since Obamacare). That means they won't be coming to see the doctor!

Since Obamacare’s Passage, Millions Have Lost Employer-Sponsored Health Insurance

4:42 PM, Nov 11, 2011 • By JEFFREY H. ANDERSON

Throughout the Obamacare debate, President Obama repeatedly promised, “If you like your health care plan, you can keep your health care plan.” Now, Gallup reports that from the first quarter of 2010 (when Obama signed Obamacare into law) to the third quarter of this year, 2 percent of American adults lost their employer sponsored health insurance. In other words, about 4.5 million Americans lost their employer-sponsored insurance over a span of just 18 months.

This is not what the Congressional Budget Office (CBO) had predicted would happen. Rather, the CBO had predicted that Obamacare would increase the number of people with employer-sponsored insurance by now. It had predicted that, under Obamacare, 6 million more Americans would have employer-sponsored insurance in 2011 than in 2010 (see table 4, which shows the CBO’s projected increase of 3 million under (pre-Obamacare) current law and an additional 3 million under Obamacare). So the CBO’s rosy projections for Obamacare (and even these paint a frightening picture) are already proving false.

Whether the decline in employer-sponsored insurance over the past 18 months is a product of Obamacare or of the Obama economy — and whether Obamacare is the principal cause of the anemic performance of the Obama economy — can be debated. But what’s clear is that, more than 25 months before Obamacare would really go into effect — if it’s not repealed first — employers are already dropping employees from their insurance rolls.

Take Walmart, for example — a prominent Obamacare supporter. Gallup writes,

“The nation's largest private employer, Wal-Mart, announced in October that new part-time employees who work less than an average of 24 hours a week would no longer be able to get their health insurance from the company. Wal-Mart laid out several other cuts to its health insurance offerings, including some workers’ ability get coverage for their spouses. Other companies have already made and will likely continue to make similar changes to their health insurance benefits….

“If Wal-Mart's decision is a precursor of how employers intend to manage their healthcare costs, the downward trend in employer-based healthcare will likely continue.”

So in addition to costing about $2.5 trillion over its real first decade (2014 to 2023), looting nearly $1 trillion from Medicare over that time (according to the CBO), forcing Americans to buy government-approved health insurance under penalty of law, and amassing unprecedented power and money in Washington at the expense of Americans’ liberty — if Obamacare stays on the books, you may like your health care plan, but that doesn’t necessarily mean you can keep your health care plan.

It’s time to repeal Obamacare.

H/T The Weekly Stantard

Obama to cut Physician Pay by 50 percent! Big Physician Pay Cuts Coming!

The worst fears about Obamacare are now being realized in a decision on Monday by the Medicare Payment Advisory Commission (MPAC) established by the law to supervise $500 billion in Medicare cuts. MPAC, whose decisions have the force of law, has voted to impose drastic pay cuts on all doctors under Medicare and, by extension, under Medicaid (which tends to follow suit). The cuts will effectively reduce the real pay for specialists by 50% over the next ten years — including a 25% reduction over the next three years — and cut general practitioners’ pay by one-third over ten years (and that assumes that inflation stays down at 3% a year).

MPAC has ruled that specialists must accept a 6% cut in their fees per year for each of the next three years followed by a seven year freeze in their fees without any adjustment for inflation. If inflation stays very low — at 3% per year — this cut amounts to an 18% cut in nominal pay and a 50% cut in real pay for specialists. General practitioners will face a ten year freeze on their pay, reducing their real compensation by one-third assuming ongoing low inflation. Higher inflation, of course, would make the cuts in real pay even more drastic.
The consequences of the MPAC decision will be immediate and drastic:
* Many physicians, and many more specialists, will refuse to treat Medicare patients. It will become very, very difficult to see a cardiologist or an oncologist or a gastroenterologist or OB-GYN specialist if you are on Medicare unless you are willing to pay out of pocket or have the kind of health insurance coverage from a private source that would reimburse for their care.
* More and more medical care will be turned over to nurses or physician assistants, and fewer people will ever get to see a doctor on Medicare.
* Private health insurers will follow in the footsteps of the Medicare program and likely slash their fees as well.
* Fewer students will enter medicine, and a major shortage of doctors will reduce the quality of medical care in America drastically.
The MPAC cuts will bring American doctors’ incomes more into line with European doctors who typically earn half or less of what their American counterparts earn — and deliver worse medical care as a result.

Hat tip to Dick Morris & Eileen McGann

States are cutting and limiting Medicaid Hospital stays

By Phil Galewitz, Kaiser Health News

A growing number of states are sharply limiting hospital stays under Medicaid to as few as 10 days a year to control rising costs of the health insurance program for the poor and disabled. Advocates for the needy and hospital executives say the moves will restrict access to care, force hospitals to absorb more costs and lead to higher charges for privately insured patients. States defend the actions as a way to balance budgets hammered by the economic downturn and the end of billions of dollars in federal stimulus funds this summer that had helped prop up Medicaid, financed jointly by states and the federal government. Arizona, which last year stopped covering certain transplants for several months, plans to limit adult Medicaid recipients to 25 days of hospital coverage a year, starting as soon as the end of October. Hawaii plans to cut Medicaid coverage to 10 days a year in April, the fewest of any state. Both efforts require federal approval, which state officials consider likely because several other states already restrict hospital coverage. Private health insurers generally don't limit hospital coverage, according to America's Health Insurance Plans, a trade group. Rosemary Blackmon, executive vice president of the Alabama Hospital Association, said "for the most part hospitals do what they can" to provide care to Medicaid patients despite the limits. In Arizona, hospitals won't discharge or refuse to admit patients who medically need to be there, said Peter Wertheim, spokesman for the Arizona Hospital and Healthcare Association. "Hospitals will get stuck with the bill," he said. Driven by higher enrollment and medical costs, Medicaid spending was projected to rise an average of 11.2% in fiscal 2011, which ended in June, from $427 billion in 2010, according to the National Association of State Budget Officers. For fiscal 2012, the association estimated state Medicaid spending will rise 19%, largely because of the end of the federal stimulus dollars. The program served 69 million people last year. Matt Salo, executive director of the National Association of Medicaid Directors, said the hospital coverage limits reflect how states are "desperately looking for any and all levers to reduce Medicaid costs" within the law. The federal Centers for Medicare and Medicaid Services is working with states to "provide them with flexibility to run their Medicaid programs and reduce their costs," Medicaid director Cindy Mann said in a statement. At the same time, "we must also ensure the Medicaid program continues to meet the health care needs of the children, people with disabilities and the elderly whom it serves."

Contributing: Kaiser Health News is an editorially independent news service and a program of the Kaiser Family Foundation, a non-partisan health care policy organization. Neither KFF nor KHN is affiliated with Kaiser Permanente.

Have Doctor's salaries increased or decreased?

This is a representative short list of Physician Salaries! Problem here is that, first the chart is from 2007, second is JAMA is off the mark! Salaries have not been that low since 1990! Peds today are earning $160k to $195k, Neurology can go up to $300k, and Psychiatry is about $230 (on avg).

DOCTORS' STARTING SALARIES

2007 averages: Radiology: $350,000 Anesthesiology: $275,000 General surgery: $220,000   Otolaryngology: $220,000 Emergency: $178,000   Neurology: $177,500   Psychiatry: $160,000   Internal medicine: $135,000   Family Medicine: $130,000   Pediatrics: $125,000 Source: The Journal of the American Medical Association

Family Practice Physicians! A coming Shortage

By Janice Lloyd, USA TODAY

Family medicine is what Doug Dreffer has wanted to practice ever since he was a second-year medical student 14 years ago at Ohio State. He listened to a different drummer from the majority of doctors entering a workforce in which subspecialties generally are considered more glamorous — and lucrative.

"All the sexy shows on TV are about ER work or surgeons," Dreffer says. "Grey's Anatomy. ER. Whatever it may be. There is no Marcus Welby on TV — 'cause it's just not cool."

Television aside, medical specialists cite an array of reasons why more medical students aspire to be Grey's Anatomy's McDreamy neurosurgeon Derek Shepherd (Patrick Dempsey), than wise family practitioner Marcus Welby, played by Robert Young in the 1970s series.

Longer days, lower pay, less prestige and more administrative headaches have turned doctors away in droves from family medicine, presumed to be the frontline for wellness and preventive-care programs that can help reduce health care costs.

The number of U.S. medical school students going into primary care has dropped 51.8% since 1997, according to the American Academy of Family Physicians (AAFP).

Considering it takes 10 to 11 years to educate a doctor, the drying up of the pipeline is a big concern to health-care experts. The AAFP is predicting a shortage of 40,000 family physicians in 2020, when the demand is expected to spike. The U.S. health care system has about 100,000 family physicians and will need 139,531 in 10 years. The current environment is attracting only half the number needed to meet the demand.

At the heart of the rising demands on primary-care physicians will be the 78 million Baby Boomers born from 1946 to 1964, who begin to turn 65 in 2011 and will require increasing medical care, and the current group of underserved patients.

GENERAL PRACTICE: New doctors avoiding most-needed, worst-paid field

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ONCOLOGY: Cancer doctor shortage expected

If Congress passes health care legislation that extends insurance coverage to a significant part of the 47 million Americans who lack insurance, the need for more doctors is going to escalate.

The primary-care doctor — a category that includes family physicians, general internists and general pediatricians — has been held up as the gatekeeper in keeping people out of emergency rooms and controlling health care costs. But medical analysts say giving this limited pool of doctors responsibility for millions more patients is problematic.

"That tsunami wave (of patients) is going to be huge," says Bruce Bates, interim dean at University of New England's college of osteopathic medicine in Biddeford, Maine.

Finding a doctor will get increasingly difficult, waits for appointments will grow longer, and more sick people will turn to crowded emergency rooms, says Ted Epperly, president of the AAFP, an association that represents more than 93,000 physicians. Or, if a patient goes to a doctor's office, he might not be treated by his doctor: One way overwhelmed family physicians have been dealing with patients is to have office visits overseen by a nurse practitioner or a physician's assistant, some of whom can dispense certain prescriptions and recommend specialists, Epperly says.

"At the time we need family-care physicians the most, we are producing the least," Epperly says. "The nation's medical schools are failing to produce a workforce that is essential to caring for America's communities."

How the gap is filled

In March 2009, U.S. medical school graduates filled only 42% (1,083) of the 2,555 resident positions for family medicine. More than 200 of the positions were left unfilled nationwide. The majority of other spots were filled by non-U.S. citizens educated internationally (20.7%), graduates of colleges of osteopathic medical schools (10.5%) and U.S. citizens educated internationally (18%).

Even the graduates of international medical schools and colleges of osteopathic medicine are showing signs of losing interest in primary care. Osteopathic training is nearly identical to traditional medicine but focuses more on the inner workings of the musculoskeletal system and puts a big emphasis on the importance of family care.

Bates says only 26% of the University of New England's grads chose family practice this year, compared with 40% "when I started this institution 20 years ago."

The shortage, which Epperly calls a "crisis," has gained the attention of the politicians looking at revamping the nation's health-care system.

"Patients with access to quality primary care are more likely to remain healthy and prevent costly and distressing chronic diseases, but the current shortage of primary-care doctors prevents too many Americans from getting the care they need, especially in rural areas," says Sen. Max Baucus, D-Mont., who plays a key role in Congress' health care debate as the chairman of the Senate Finance Committee.

Congress is looking at bills that could help doctors who choose primary care with loan forgiveness or other debt relief and payment increases for their services.

Medical school tuition and expenses generally range from $140,000 to $200,000, according to Merritt Hawkins & Associates, a leader in recruiting and placing physicians. A primary-care doctor usually makes $120,000 to $190,000 a year, compared with $530,000 and higher for those in neurosurgery, according to the Merritt Hawkins salary survey from 2007.

Dreffer is still paying back his loans to Ohio State but says he made the right career choice.

"Absolutely. For me it's about why I came into family medicine," he says. "I consider it a privilege. I like people. I like relationships. That's what family medicine is about. It's not about doing procedures or a cool heart bypass. You get to be part of your patient's life story."

He has seen interest in family medicine change as the medical director of training programs at Family Health Centers in Concord, N.H., and Hillsboro-Deering, N.H.

"More than half of the spots filled are by non-U.S. medical graduates," Dreffer says. "Our pool used to be mostly U.S. medical graduates." One problem with using foreign students is the draining of talent from their home countries. Another is their English-speaking skills, which might make communication with patients more challenging. All are required to take stringent exams in the USA, however. An upside is their willingness to work in underserved areas often rejected by U.S. graduates, including rural areas and inner cities, according to studies done by the American Medical Association.

Part of the reason U.S. medical school graduates are rejecting primary care, Dreffer and Bates say, is because some U.S. schools promote subspecialties or research, higher-paying careers with more prestige.

"I would put a lot of weight on the culture of the school being a big influence," Bates says, adding that doctors pursuing family medicine often will hear, "you're too smart to be in primary care."

Eleven of the top allopathic (conventional medicine) medical schools, including Harvard and Johns Hopkins, have internal-medicine departments but lack separate family-medicine departments. Most internal-medicine doctors get out of primary care and go on to specialties within five years of leaving school, says AAFP's Perry Pugno, director of the division of medical education.

"I think the way you get exposure and cultivate it plays a role," he says. "In some of the bigger schools that generate more primary-care positions by percentage — some of the state schools and osteopathic schools — they have better mentorships and exposures early on."

A shift in training

Training of family-care physicians has been evolving as the supply of doctors decreases. The fictional Marcus Welby symbolized an era in which many doctors handled nearly all aspects of a patient's care. That is not always the case now.

Pippa Shulman, 35, completed two residencies at Dartmouth and begins her first year of family practice Sept. 1 in Massachusetts for Harvard Vanguard Medical Associates, where the team approach is practiced. She is a graduate of the UNE college of osteopathy.

Her residencies "tied into what is the hot topic now: the patient-centered medical home and really creating a primary-care home for patients," she says.

The medical home approach surfaced in the '90s and delivers service that is supposed to be better-coordinated, family-centered and more accessible with expanded hours. Nurse practitioners and physicians assistants play bigger roles in office visits and relieve physicians of other time-consuming tasks so they can focus on the continuity of quality care. "Home" implies continuous, preventive care rather than seeing the doctor only for acute problems.

Experts say getting more doctors to be generalists is an uphill climb in a health care system that rewards doctors based on the procedures they do.

"The biggest problem is the payment model," says Sameer Badlani, an instructor at the University of Chicago's school of medicine. "The more procedures you do, the more money you make. That is why, in a procedure-based specialty, a physician can make about four to five times the annual salary a primary-care physician can earn."

'There is hope'

And that's why specialists like Grey's Anatomy's McDreamy are envied and why fewer students will follow Shulman's path into family medicine, Epperly says.

"I really love being a generalist," Shulman says. "Primary care is fun. I always say I'm a generalist in a specialist's world."

Badlani urges students to consider primary care.

"I give a lecture to medical students basically on not letting debt affect your career choices," he says. "And my aim was just to convince one out of the 100 students who attend. That's where I set my benchmark. If I can convince just one person, I will have done my job.

"I have had three or four students come back to me and tell me they did not want to go into primary care but now they will rethink. There is hope."