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Old 25th August 2019, 10:50 AM   #81
kellyb
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Originally Posted by xjx388 View Post
I think it's largely a myth that the AMA artificially limits the number of doctors. A major factor is residency slots, which are funded mostly by Medicare and Medicaid. The number of positions funded is capped by law. Another factor is the number of med school slots. State Licensing schemes are another factor. The AMA does not have control over any of those things.
The AMA does convene the RUC for the CMS to determine Medicare payments:
https://www.wsj.com/articles/SB10001...40440173772102

Quote:
Physician Panel Prescribes the Fees Paid by Medicare
By Anna Wilde Mathews And Tom McGinty
Updated Oct. 26, 2010 12:01 am ET
Three times a year, 29 doctors gather around a table in a hotel meeting room. Their job is an unusual one: divvying up billions of Medicare dollars.

The group, convened by the American Medical Association, has no official government standing. Members are mostly selected by medical-specialty trade groups. Anyone who attends its meetings must sign a confidentiality agreement.
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Last edited by kellyb; 25th August 2019 at 10:52 AM.
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Old 27th August 2019, 12:22 AM   #82
xjx388
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Originally Posted by kellyb View Post
The AMA does convene the RUC for the CMS to determine Medicare payments:
https://www.wsj.com/articles/SB10001...40440173772102
Not entirely accurate, but it's a complicated subject. Feel free to skip the next part where I try and explain how it works. TL; DR: CMS sets the actual prices and the RUC just advises CMS on what each individual procedure should be valued at.

Medicare sets its fees on a Resource Based Relative Value Scale. Each CPT code (the code each procedure gets billed under) gets a value assigned to it called Relative Value Units (RVU). An RVU is made up of three components: Physician Work RVU (wRVU), Practice Expense RVU (peRVU) and Malpractice RVU (mRVU). The idea is to value each procedure doctors do relative to each other. The RUC is involved in setting the Physician Work value for each code and also has input on the Practice Expense value. CMS handles the Malpractice value. For example, the most common CPT code billed is 99213, which is an established patient visit, level 3 -your everyday doctor visit. 99213 has .97 wRVU, 1.05 peRVU and .07 mRVU for a total of 2.09 RVUs. Compare this to something more complex like CPT 44950 for an appendectomy: 10.60 wRVU, 5.56 peRVU and 2.46 mRVU for a total of 18.62. So an appendectomy is valued about 9 times higher than a routine office visit.

The RVU is where the RUC has influence. CMS has the final say in RVUs but they usually accept what the RUC recommends. Which makes some sense because actual practicing physicians are in a better position to determine the work and expenses involved in providing services. The primary tool the RUC uses to set RVUs is physician surveys.

This only sets what each procedure should be valued at. The other component of price is the conversion factor (CF), which is the dollar amount Medicare pays per RVU. CF X RVU = Medicare price*. 2019's conversion factor is $36.04 so 99213 will pay $75.32. The CF is determined according to some arcane formula set by law. The current formula basically ensures that payments will not rise or decrease by certain amounts.

The AMA doesn't control the price of services, only the value that each procedure will have. Congress controls the actual prices paid through the CF.
I don't think this is as nefarious as it is often made out to be. The article you quoted makes it sounds like the AMA divvies up the billions of dollars in some back room shady dealings. Like I said, doctors and specialty groups are in the best position to value each procedure they do relative to other procedures.



*I'm leaving out the geographical adjustment which basically accounts for the higher costs in say, Manhattan. Basically, more expensive areas have their RVUs bumped up a bit.
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Old 27th August 2019, 01:40 AM   #83
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Originally Posted by Seismosaurus View Post
I was thinking of somebody using private medical services exclusively. There are private GPs, private hospitals, etc so you can do all your medical stuff without the NHS, I think. But I guess you could use the NHS for routine stuff and only use private insurance to get faster treatments when needed. A bit of both worlds since you're paying for both.
In the UK most GPs (primary care practitioners) are 'private'. GPs run their own businesses usually as partnerships. New partners have to buy their way in. Some may own their own premises, others may rent space in NHS health centres. The NHS pays them to deliver care, as defined by a national standard contract, but locally add ons may exist. The NHS pays a standard fee per person (which does vary by age), plus fees for e.g. providing contraceptive services, vaccination services, screening etc. The partnership will employ nurses, doctors admin staff etc (although on nationally agreed contracts). The partners share in the profits.There are fully employed GPs usually in more rural areas where running a business may be more challenging. The partnership may earn additional money from e.g. providing occupational health services.

https://assets.publishing.service.go...nal-report.pdf


In contrast hospital staff are directly employed.
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Old 27th August 2019, 09:34 AM   #84
xjx388
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Originally Posted by Planigale View Post
In the UK most GPs (primary care practitioners) are 'private'. GPs run their own businesses usually as partnerships. New partners have to buy their way in. Some may own their own premises, others may rent space in NHS health centres. The NHS pays them to deliver care, as defined by a national standard contract, but locally add ons may exist. The NHS pays a standard fee per person (which does vary by age), plus fees for e.g. providing contraceptive services, vaccination services, screening etc. The partnership will employ nurses, doctors admin staff etc (although on nationally agreed contracts). The partners share in the profits.There are fully employed GPs usually in more rural areas where running a business may be more challenging. The partnership may earn additional money from e.g. providing occupational health services.

https://assets.publishing.service.go...nal-report.pdf


In contrast hospital staff are directly employed.
Sounds like most GPs in the NHS are private practices very much like the one I manage here in the States. Except they have only one insurer and that insurer has them on what we would call a capitation contract -they get paid per registered patient per month. According to figures from last year, that payment averaged 152.04 per year. That's about $185 per patient per year . . . so let's apply that number to our situation here in the States. We have about 9500 active patients in our clinic so that would mean we get about $1.8 million per year. That wouldn't even meet current overhead without clinician salaries which is about $2.2 million/year. To be fair, you have to consider that if all our patients were on this contract, our overhead would be much lower. So, let's be really generous and reduce that number by half and say our overhead under that scheme would be about $1.1 million. That leaves about $700k to pay 7 clinicians -3 doctors and 4 PAs. That would amount to a huge paycut for our clinicians. We would have to somehow lower our overhead even further which might be possible but it's hard to contemplate.

The big issue is that an NHS style scheme would mean primary care providers in the US would take a substantial pay cut. I imagine the same would be true for specialists; from what I can see, specialist pay is much lower in the UK than the US. That's going to be a very hard sell.
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Old 27th August 2019, 10:24 AM   #85
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Er not quite.

The NHS figure you quote is for what they get paid per patient, it does not include the GPs pay, that is usually a separate NHS contract which as an average will be paying around 70,000 basic salary.
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Old 27th August 2019, 10:29 AM   #86
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It is also not true that the best pay is causally linked to UHS v private.

Look at this short article, a bit fluffy but seems to have got its figures right.

https://www.careeraddict.com/top-5-c...es-for-doctors
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