Question:

Is there a benefit from the expansion or existence of the smaller highly specialized medical delivery facilities or not? If this aspect of OC does not kill them off then it seems the only way they survive is through investment of large corporations or more likely small business investors. I get that Obama thinks diagnosing doctors referring patients to procedure facilities that the same doctor owns might not drive up costs BUT. If the net result is fewer and potetially less skilled facilities then this seemingly fascist move is exactly the wrong direction when we are supposedly are going to be facing a shortage in delivery systems. Besides since when could the government dictate which citizens can own or invest in a business?

My Answer:

I don't see Obamacare killing subspecialty state of the art clinics off.  Check out Cleveland Clinic's websites on ACA. They have a number of these clinics, and don't fear Obamacare although they and many others have offered constructive criticism.  As you know, in reality much of Obamacare remains to be defined, and that's not necessarily the fault of Obama, or Zeke Emanuel or the architects of Obamacare who had it compromised by Republicans on the Senate Finance Committee and Leiberman, Ben Nelson, and Landrieu who all are functional Republicans because they delayed the start date. I would have much preferred the plan Dr. Dean outlined--single payer or public option--medicare for all.


Of course there is a benefit from smaller highly specialized medical clinics, and a large number of practices in my city follow that model ranging in size from 8 subspecialists to 60 in the case of some of the larger cardiology practices.  I support them as strongly as possible.

My brother-in-law was trained as a thoracic and general surgeon and after years of covering thoracic and general surgery trauma and practicing general surgery at a very high level he helped start one of the leading breast cancer clinics in the country that delivers state of the art care.  This cinic is a model and has been thriving for 16 years. Their hospital where they do surgery is one of Columbia University Medical Center's top teaching and largest hospitals, and they do state of the art outpatient surgery and diagnosis as well. Their clinic isn't impacted by this part of the ACA because the hospital corporation owns the clinic but the docs run it totally.  Administrators don't run this hospital--the doctors do in every possible way, and for a period of time after getting an MBA, my borther-in-law served as administrator as well as Chief of Surgery and Chief of Staff.

There is in fact a trend now for physicians to move to mid-sized of small single specialty practices that  has been underway for years.

I couldn't agree more with your concern about the ACA's ban on physician owned clinics that aren't grandfathered in so that they are untouched by this new part of the law, and have full CMS billing privileges after the date conflict was resoved between Don Berwick and the AMA.

The purpose of the law was to prevent surgical clinics from masquerading as hospitals, and it would have  several adverse unintended consequences and I would not have voted for it and would have opposed it,  but I fully back the legal fights (and there are several now) to take that portion of the ACA down.

This is an example of the suits up and running to try to overrule this component of ACA.  The ACA is a work in progress, but the vast majotity of the criticisms I've seen launched here if they can even be dignified as criticisms since they are usually delusional invective from the right wing echo chamber and the $230 million dollar misinformation campaign propelled by insurance companies on the down low.

Doctors fight hospital ownership rules under Affordable Care Act
http://www.bizjournals.com/phoenix/print-edition/2012/07/13/doctors-fight-hospital-ownership-rules.html?page=all

The ACA has many constructive components and several are outlined here:

WAPO's Wonkblog and NYT have done an excellent job of showcasing the truth about the strengths of the ACA as well, not to mention the superficial hoax RR have tried to perpetrate on the American people using math that a second grader knows is bogus.

ACA Is a Giant Step Forward
http://www.internalmedicinenews.com/index.php?id=495&cHash=071010&tx_ttnews[tt_news]=137449

11 facts about the Affordable Care Act
http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/06/24/11-facts-about-the-affordable-care-act/


-- Modified on 10/20/2012 11:36:33 PM

I merely restated his case without the speculation in the manner he stated it. Maybe if you weren’t so quick to tell all how stupid we are you might recognize additional similarities we share. I’m sure this is but one of many unintended consequences. The bill is so poorly and loosely written it is filled with many more opportunities for unknown unintended consequences to surface. There are several that are already known.

The law does many things but I do not see how any of them will curb the PER UNIT inflation rate of health care delivery. There are many good things that it accomplishes from a patient benefits standpoint. We should scrap the rest and find a way to put more competition back into the payment of delivery (not just more competition for insurance).

Insurance companies haven’t been able to control the inflation, Medicare plus insurance companies haven’t and the Democrats goal of more government (and eventually all government) won’t be able to either. Tell me what the prices of elective eye correction surgery have been doing, or the prices of elective cosmetic surgery. If the many millions of people were put back in the payment loop there could theoretically be millions of price watchdogs.

Thank you RB!!!!!!!!!!!!!!!  YES, YES, YES,   COMPETITION is what we need,  not government intrusion in EVERYTHING.  Competition drives prices down,  but RB you forget our wonderful government does not like competition,  because as we all know very well that the government is "in bed" with big business's (and I'm not talking private businesses like Bain was,  I'm talking businesses that are publicly held because their only accountability is to their shareholders and, of course,  our government).

Check out "Life Extension" (Doc you should appreciate)  http://www.lef.org,  which I have been a member of for a number of years,  their research/ theories and fact findings have been far superior, IMHO,  of course,  to that of their publicly owned counterparts.  They do blood work that a lot insurance (at far less cost)  companies won't pay for,  for instance,  glutathione tests,  when I went for my "bioidentical harmones"  the Dr's  (yes,  if you become a member,  they even have Dr's to "bounce ideas off of,  so when you go back to "your Dr"  you don't look like a schmuck)   at L.E. said,  "make sure,  your Dr also has such and such a test done",  my Dr,  said,  that is a good idea,  where did you obtain that info,  I told him,  Life Extension, he just said  HMMM and proceeded to write the prescription for the blood work to be done.

Anyway,  short and sweet, here this morning,  almost 7AM and I am off for a 20 mile bike ride.  
A marvelous Sunday to all
Cherie

Cherie blithly pretends we have no problems with uninsured people, pre-existing conditions, or life caps which drop people when they need significant medical care for chronic conditions or surgery when they get older.  All these life enhancement programs don't do a damn thing to stop the very real problems that we have 85 million or so uncovered until ACA begins to cover them, and that'll be diluted by the moronic governors who resist Medicaid expansion although that number is quietly dropping.

Marikod also linked his question to a ridiculous assertion that went like this:  (He didn't really talk about the provision in the ACA that would prevent physician owned clinics at the end of 2010 according to a negotiation after a letter from the AMA President to the CMS director that I've read.

Marikod said that if there weren't subspecialty clinics owned by physicians, general surgeons wouldn't be scrubbing to do abdominal approaches to back surgery.  The problem with that was that doesn't happen on planet earth in any operating room.  If a general surgeon is scrubbing with an orthopedic or neurosurgeon, it's due to multiple trauma being attended to not elective or emergency back or spine surgery per se.

I was happy to respond to a clearly framed relevant question.  And to marikod, I still clean MY toilet, bathtub, bathroom and do an excellent job.  I learned at an early age.  If that makes me my own janiot, so be it.  When I do it, I don't see my diplomas go up in flames and afterwards I still remember the medicine I know and read every day. I get 3 grand worth of medical information in my inbox free every month--so  someone takes care of janitors pretty well as to CME.

Marikod framed his question that if there were no subspecialty physician owned clinics, there wouldn't be any more general surgeons scrubbing with neurosurgeons and orthopedic surgeons for spine and back sugery.  That caught my eye, because there isn't anything that ridiculous going on with an implied abdominal approach via laporoscope to back and spine surgery on planet earth.  Back and spine surgery is done from a posterolateral or posterior approach, unless you had multiple trauma that would include the abdomen and in that relatively rarer situation then there might be two stages depending upon the priority of what trauma surgery needed to be done first to stabilize the patient.

Cheri blithly preaches all these self improvement programs and they are fine if they make someone happy, but they do NOTHING to solve the problem that we have 85 million uninsured under Romney's  plan that won't see the light of day, and we have pre-existing conditions and lifetime caps by the insurers that the ACA eliminates.  None of Cheri's programs have these constructive components in them or do a damn thing to fix a broken system that isn't delivering medical care to millions of people and is driving them into ERs that aren't appropriate to do chronic care.

ACA Is a Giant Step Forward
http://www.internalmedicinenews.com/index.php?id=495&cHash=071010&tx_ttnews[tt_news]=137449

11 facts about the Affordable Care Act
http://www.washingtonpost.com/blogs/ezra-klein/wp/2012/06/24/11-facts-about-the-affordable-care-act/




-- Modified on 10/21/2012 9:16:26 AM

You want competition, right. You think Health Care cost is going up because lack of competition.

If you believe it, then you are clueless.

It is no longer a question of competition, it is question of how the competition is behaving.

Wise man once said: There is enough for man’s need but not enough for man’s greed. Greed is the problem society is facing today.

Same wise man said: Capitalism left unchecked makes the rich, richer and the poor, poorer! which is what is taking place in the larger society (larger society meaning not the mythical one you think exists in your neighborhood).

The new law may bring down national costs but I do not see how the main component of that reduction is not through either straight rationing or some kind of reduction of services.

What about my question regarding the price trends of services not covered by insurance compared to covered ones?

BTW, marikod corrected his mistake, clarifying that he did not mean general surgeon but instead meant any surgeon at a general hospital as opposed to a specialty hospital. But it was too late, emotion already had been unleashed.