Originally Posted by SteveZ

...Most medical practices have a significant net worth. Nationalization zeroes that value. I can already imagine the court cases on that....

That might be the primary obstacle to getting doctors to work for a salary. It may well the the "legal impediments" that the doctors on the CNN show were referring to.

It can be done, but it would take fairly large groups of doctors to organize a combined practice, taking all the insurance payments into a central pool and then paying the doctor-members a salary. If I understand correctly, the way the Mayo Clinic and the Cleveland Clinic work is that they provide the service and hand the patient the bill. The patient pays the bill and collects what he can from his insurance company and/or Medicare. It seems to me that's the only way the economics of a "salaried system" might work, unless all the doctors agreed to take a pretty significant cut in income when they went to a salary. That may be in the offing, as well. My understanding is that U.S. doctors have income levels that may be double what they are in countries with nationalized medicine.

Originally Posted by Villages Kahuna

That might be the primary obstacle to getting doctors to work for a salary. It may well the the "legal impediments" that the doctors on the CNN show were referring to.

It can be done, but it would take fairly large groups of doctors to organize a combined practice, taking all the insurance payments into a central pool and then paying the doctor-members a salary. If I understand correctly, the way the Mayo Clinic and the Cleveland Clinic work is that they provide the service and hand the patient the bill. The patient pays the bill and collects what he can from his insurance company and/or Medicare. It seems to me that's the only way the economics of a "salaried system" might work, unless all the doctors agreed to take a pretty significant cut in income when they went to a salary. That may be in the offing, as well. My understanding is that U.S. doctors have income levels that may be double what they are in countries with nationalized medicine.

The kicker is the "value of the business" for each medical office. These medical offices are businesses incorporated under state law, and to terminate these corporations by a federal act and require individuals with state-issued professional licenses to work according to a federal mandate is no light-hearted legal matter. Voluntary associations are one thing, but federally mandated groupings of professionals is another. The last time I checked, that qualified as conscripted service, as a minimum; with confiscation and/or devaluation of assets and professional 'slavery" as a potential claim.

When Canada went through the metamorphosis to national care, they did it at the provincial level. That made great legal sense, as that solved the incorporated-entity issue and provincial professional license issue at the correct jurisdictional level - one at a time. Eventually, after all provinces established their separate systems, they were able to link the provincial systems with regards to funding and elements of standardization.

Let us not kid ourselves. There are massive State's Rights issues involved, and the Federal Government does not have the authority to terminate a state-granted corporation or revoke a state-issued professional license. So, to autocratically (federal) change business models and impact state corporation grants and state-issued professional licenses, those are those "nasty details" which the HR 3200 proponents are trying to shove under the rug. 10th Amendment, 13th Amendment and 42 USC arguments will abound, and HR 3200 may not stand up to Constitutional and civil rights scrutiny - all in the protection of medical professionals, with the government (a.k.a. taxpayer) getting the bill for recompense for business damages and legal fees. Just because a bill gets passed by Congress and signed by the President does not mean it is Constitutionally sound and that the Supreme Court can't toss it if the statute is challenged.

HR 3200 may end up being a lawyer's dream. The cases which this bill will probably spawn - just the ones from medical professionals against the government - could make the Tobacco and Asbestos cases seem like peanuts. With all the potential money to be made advocating for medical professionals, I may even have to come out of retirement for this (no, I wouldn't, am having too much fun in TV! Am not going back to DC for any reason!)

This will be funnier than "Boston Legal" reruns!

You state the potential problems so succinctly, Steve. What worries me is that if the 435 somehow missed the thought that they way they wrote the C4C law would result in a lot of money filtering off to foreign lands, is there a chance they missed the potential of this problem?

Originally Posted by Villages Kahuna

You state the potential problems so succinctly, Steve. What worries me is that if the 435 somehow missed the thought that they way they wrote the C4C law would result in a lot of money filtering off to foreign lands, is there a chance they missed the potential of this problem?

I made a decent living based on the fact that laws were confused, conflicting and downright unconstitutional.

Wait until the later discussions we all will have on "comprehensive immigration reform." If the McCain-Kennedy bill had passed, that would barred any federal prosecution of anyone - citizen or non-citizen - for identity theft and many other felonies due to "suspect class" issues, and would have made no dent on employer violations even with a couple thousand more ICE agents hired specifically for employer review (because no increase in the size of the court which handles those cases was included, and that would have stretched court dockets out several years, resulting in dropped cases)

Legislators don't care if the resolutions/bills are legal. All that matters is that they generate headlines and publicity to carry them through the next election. This President taught Constitutional Law, so he knows HR 3200 is a mess. It's crazy....

Again, the "law of unintended consequences" strikes every time something is rushed through the legislative system.

When the talk is about paying for quality instead of quantity they are referring to outcomes. Do Dr. Y's patients with Type 2 Diabetis maintain HgbA1C levels of 6.5 or below? Do Dr. Y's Type 2 Diabetics get a HGBA1C ordered every 3 months? The various forms of how outcomes will be used for payment reform is yet to be decided. It is currently in an embryonic stage in the Medicare program called PQRI and was not very sucessfull for clinics.

One of the things being wrestled with is how to look at outcomes when the patient does not follow recommended treatment.

Because of the high costs of running a private clinic and the ever dwindling reimbursement for services most Primary Care Physicians have already joined some type of employer.

The more concerning issue is that there are fewer and fewer med students who select this field.