birdog1960

yes. gave up my small group practice a few years ago to work for a large system. part of the reason was the need to switch to ehr. we had one for years but i never wanted to go through the slow down (and expense) needed to learn and utilize it so we did paper..and, i believe, it served the patients and us well . i do see the advantages of ehr but the systems are far from perfect and it's clear that there were too few clinicians involved in the design of our systems'. why the big players like microsoft or especially apple aren't in the game is beyond me. apple would never put out a buggy product like many of those available. anyway, my perception is that healthcare reformers fully understand the need for a strong primary care base to successfully achieve their goals. they've already thrown a few bones our way and i think there will be more to come. unfortunately, these will likely be at the expense of proceduralists. outpatient primary care is where the growth will be in my opinion..and where it should be if were going to provide more quality care to more people at less cost. some system administrators share this belief. others just seem to see the present ...i think that's a big mistake. systems like geisinger and kaiser have known it for a long time. tech is ok but it's the docs that make (or don't make) the difference. without them, hospitals are just very expensive hotels with bad food.

as you said, this isn't new and wasn't started by obamacare. private practice has been a dying dinosaur for quite some time. if you're still in it and haven't made the jump you're proabably doing worse financially than your colleagues that have are (excepting concierge practice which has it's own headaches). obamacare will push this faster however. i believe we're moving towards bundled payments for overall care and accountable care organizations. hard to do that and compete in a small practice. probably eventually going to move away slowly from fee for service (via bundled payments and more in line with the kaiser type model). fee for service just doesn't work for cost effectiveness. quality will be compensated and already is. be damn near impossible to get quality bonuses if you can't measure quality with electronic medical records which some small practices still don't have. medical home is an interesting and promising prospect for internists, especially. most of us have been doing this all along (acting as the patient's advocate and "orchestra conductor" for care, if you will. now were going to get paid for it. and that should incentivize more docs to do it. most of these things are good in my opinion. hate to see small practices go away but that's more out of nostalgia than a belief that they are a better mousetrap. all of this would have happened with or without obamacare. it's just happening sooner with it.

the last conference i went to there was at the venetian. my wife came to that one and was immediately lured to the big dollar slot. put in a dollar or whatever it was and watched a winner line up only to have it click over to a loser a good seond or 2 later. that cured us for the rest othe stay. a dollar well spent.

i enjoyed the shows and the food and drinks. gambling's not my thing so that's probably why it doesn't appeal to me so much. we've gone to tahoe several times to ski. now, that i love. a beautiful place with great skiing and relatively cheap hotel rooms and food cuz they figure you'll gamble.

riding the elevator down to an early morning meeting can be interesting. the beautiful women you saw the night before don't look so great after a night of work. in general, vegas isn't as attractive in the morning light, to me. to each his own.

well, at least were not wasting time over a semantic debate about more often versus greater percentage. i think bacevich understands the full context better than most. he clearly sees the casualty gap as a travesty. and i can't find fault with his reasoning.

and i'm telling you to read the book or the review. bacevich is more eloquent than i'll ever be in this piece. and with much more knowledge and experienced on the issue. you don't need me to define it to understand my point. it's all right there.

a nice summary and review of the book from an important perspective for those not inclined to read it. the author is a west point grad, career military, whose son was killed in action in iraq. i especially like his last 2 paragraphs. http://www.thenation.com/article/154459/unequal-sacrifice#

read the book. it's full of tables and jargon. you'll no doubt enjoy it. you're a peach

in brief response: poorer people die more often in recent american wars. http://juneauempire.com/stories/053110/opi_647103553.shtml. is that not an important measure?

thanks...no wonder i don't understand the law. it appears solvay went into an agreement with 3 different generic companies divying up some production and marketing of the brand name drug among the 3 and paying them 10% of the revenues from the drug for the services in exchange for them not taking on developing the product as a generic.. they argue that this arrangement isn't collusion although the goal was very clear. seems sleazy to me and clearly not in the best interests of competition or of the consumer. mind you, this started in 2003. think of all the bucks paid out by limp consumers unnecessarily over that time. not to mention the bad effects of the "do you know your T level ads"playing incessantly on tv. maybe it's legal. whenever i discuss such issues socially with lawyers, my jaw drops and my head spins. sure doesn't meet the smell test to me. if this is ok, then, it seems to me, that the system is rotten.

well, that's what i thought too, but i'm frequently confused by the law...what could possibly be the arguments against it being collusion? why should it take the supremes to decide this?

as chef would say, yes Yes, YES! it was a mistake. probably payback for the drug co's supporting the ACA. if a few repubs supported it and there was more cooperation in congress that might not have been needed. but seriously, the repubs supporting hurting big pharma? dems were probably bought off late int the game but they've been owned for a while. remember the medicare drug civerage legislation? i see this as a litmus test for whether we are truly and completely a corporatocracy....the drug co's win here would confirm it.

i suppose my point is the number you threw out is not a benchmark on which to consider the effect of reform on specialty choice. these are atypical conditions. and, btw, the reason they are "subsidized" is likely 2 fold: they're not producing median or better rvu quantities and rvu's have been adulterated beyond the recognition of the original concept. we now have different dollars per rvu for different specialties when the original purpose was that rvu's (relative value units) were equal amounts of work value. that's what reform is, in part, addressing - a return to that concept that equalizes payment for relative work value. if the rvu concept is ever used as it was meant to be, you'll see an increase in primary care residents and consequently, doctors.

wow. then they either need to look for work elsewhere or see more patients. that's about 30% below mgma median 3 years ago. there probably below the bottom quartile.

unanimously against the drug co and for the dept of commerce...seems like a no brainer. but i doubt it will be unanimous among the supremes. should be interesting. like to see scalia explain a vote for the drug co's here.

cool. i really thought this one would be unanimous. there's a clip on the npr report where the drug company's lawyer is defending the practice at a georgetown law school lecture. fairly hysterical laughter can be heard in the background.. wonder if any of the supremes will laugh.

agreed. it shouldn't have. which was likely for the same reasons that the kind of legislation tasker wants won't be considered any time soon. still, its only tangentially relevant to this case. this about much more than drugs.

in the case of drugs, we already pay more than just about anywhere else for the same drugs. and the utilization and early availability of generics are among the worst. so, in this case don't think your argument holds up, at all. we can't compete on copyright laws with places like china that treat patent rules with wanton disregard. does that mean everyone should disregard them? isn't that very likely to disincentive invention? there's a difference between patent law and collusion. i think this case illustrates it quite well.

you all are totally left brained....what if this was about seed for grain? what if monsanta paid off ADM to not use their tech after the patent expried on it. and ADM complied globally, stopping consumers from getting cheaper food. isn't anyone the least bothered by what appears to be a very anti competitive practice that hurts consumers for the benefit of big industry?

many of these companies are multinationals. your solution doesn't address that. they casn collude globally. and you're talking about an act of congress. this legislation isn't forthcoming.

but that's not what's in front of the supreme court.

http://www.npr.org/2013/03/25/175043758/supreme-court-hears-pay-to-delay-pharmaceutical-case. should be an interesting hearing. as you might guess, i side with the dept of commerce. comments?

they are incentivizing primary care and disincentiving proceduralists...a strategy that has produced better outcomes at lower cost the world over. just the opposite of what has happened here over the last 50 years because the more you do the more you get regardless of outcome....which is really stupid. so, we'll see more midlevels doing what they were originally supposed to do: primary care. and primary care doctors will oversee the teams of midlevels. as the editorial says, there will be bumps in the road but the goals are worth pursuing. it will take longer to get elective procedures because there will be less proceduralist capacity but the outcomes should still improve just as they have in virtually every other system in the world. the big winner is meant to be the overall health of the nation, including that of the 50 million uninsured. the success or failure of the insurance industry and the healthcare industry shouldn't matter outside of this goal.