Who would pay the salary? What would happen to the docs in private practice? If someone, like the government, paid my salary, would they then come and pay my overhead expenses? If not, I would not be able to continue my practice with overhead costs skyrocketing.
For example, if we look at vaccines, we all know that our reimbursement barely covers the cost. If I have to pay for them without getting reimbursed, I could not afford it.
I think the statement that all doctors should be salaried shows someone who is completely out of touch with how healthcare works in our country.
And the president's statement that we get paid by doing more tests is ludricous. We send out most tests and have no financial interest whatsoever in ordering these tests. And the procedures we do in the office, there is a cost to us to do (i.e. the example of vaccines). Also, if we do a blood sugar test or U/A, we are paing for the supplies to do these tests and most of the time we are lucky if the reimbursement covers the cost.
Dan: what if we write our own healthcare reform proposal and take it public. We are the ones on the frontline and really know what's going on. This will make it seem like we care about real reform rather than just fighting against ideas of idiots.
I really appreciate what you are doing for us and am proud to have you as a voice for our interests. Thanks!

I agree with the comments of DOCLMG.

If we are on salary then we are employees of some entitiy. It would then be the entities responsibility to pay for all the expenses associated with medical practice (employees, benefits, medical supplies, rents, leases, malpractice insurance). Being salaried would also make it less attractive to work harder to better ourselves (why work 80 hours when I make the same working 40?). does being slaried mean I also get vacation time? How about sick time or FMLA time? Diasability?...there are just too many variables for octors to be "salaried"

I also agree that we could look at various ideas on how to change healthcare so that we dont look oppositional all the time. We understand better then anyone what we as physicians go through. We may not understand all the legal mumbojumbo associated with insurance regulations but we could write some basic premises to present as what we think would be best for healthcare, patients and doctors. This would be time consuming and require research into costs of various ideas.

In other countries where there is socialized medicine and doctors are salaried, usually docs get their medical education for free. It is an investment by the country. On the other hand, we invest in our own education and come out with 150K - 200K in debt. Would govt pay for our educational debt and our overhead and our liability???

It's not really a question of if we should all be on salary, it's a question of if we support socialized medicine/universal health care/government-run healthcare.

If you work in the VA, you are a salaried physician. For the most part, this works- you do not have overhead, you do not pay your staff, your malpractice is covered and backed by the gov't, etc. etc. We don't all work in the VA, and we don't all want to. In my opinion, if you can build a better mouse trap by either not accepting insurance, or accepting insurance and still coming out better than being on salary, more power to you. We should have that freedom.

If patients are allowed to choose between government insurance and private insurance, we should be able to choose between salaried and no-salaried jobs, respectively.

The government has been trying to eliminate small physician private practices with only 1 or 2 doctors for years. Medicare and Medicaid have made it hard on the small businesses. Now they want to eliminate private practice altogether and make us all salaried employees - of the government or of a large corporation. It would certainly symplify things from their point of view. But it would destroy medicine, eliminating the choice to be your own boss. It is a form of slavery. And it would markedly decrease (again) the number of primary care doctors, as they leave medicine entirely. It would build another wall, the wall of bureaucracy, between the patient and the doctor. Howard Dean had his own practice, didn't he? This is a horrendous idea and needs to be crushed.

Agree with above. I think that physician practices are very heterogeneous. Who would set these salaries, and more importantly who would pay them?

What would we do about our medical education system? Would all medical school tuition be the same?

When you salary docs you take away incentives to work.

If I'm going to get paid the same for seeing 30 patients/day as I am to see 10/day, then I am going to see 10/day.

I think if we moved to a true socialized system that we should be salaried. These salaries could be based a few models

1. Specialty base pay, based on number of years of training rather than other arbitrary criteria.
2. Number of years of experience
3. Potential for increased salary to provide care in underserved areas

I would be happy to work in such a model, if my overhead were covered, and especially if medical school were paid for. If we moved to such a model now, it would be just to provide retroactive forgiveness of government medical school loans.

'The most terrifying words in the English language are: I'm from the government and I'm here to help.' - Ronald Reagan

Howard Dean's a certified dimwit...I'm in solo practice in a rural isolated area accessible only by air. How do I get salaried? And if its less than I make now, am I willing to abandon my patients and cut back on my load, because thats what "salary" means? I usually see 50-60 patients a day in my office and 1 to 3 patients in the hospital and I'm on call for the hospital 8-10 days a month. Actually, cutting back might be nice for my sanity but I don't think I could sleep at night.

The UK has socialized medicine and 1/3 of their docs are foreign born. Not knocking foreign born, but why aren't their own best & brightest going into the profession?

I do believe all hospital administrators of "not for profit" hospitals should be on salary, without any "performance bonuses" (aka gain sharing arrangements).

Whoa, easy Howie.....All physicians being salaried goes beyond a Single-Payer system and straight to fully socialized medicine. Anyone within earshot of the UK would say this is a terrible idea....

For anyone who hasn't read this (including, obviously, Howard Dean):

Sermo Doc

Spoken like the uninformed a-hole he is. Sounds great, provided the government pays for medical education, pays my office expenses, pays my malpractice premiums, and I get the perks most government employees get: paid vacations, pension, and health coverage (although in this system, I might have to pay out-of-pocket to get better quality care).

Salaried=Socalized medicine=Reduced quality and access.

This is a simple equation.

Obama and his lackey Howie, have stated, that we won't get Tort reform.....How does that work, if the Gov't is paying our salaries???????????????

There can be no healt care reform without meningful tort reform as its cornerstone.

I agree with amdcu93 - salary means less incentive to produce. In a salaried position you have no positive reinforcement to work harder. I also agree that it would, overall, reduce the numbers of physicians, be they primary care or specialists.

If I'm paid what I consider is a reasonable salary and my employer pays my benefits and malpractice insurance on top of my slary, then maybe it's a good idea. Otherwise, I'll go be a lumberjack.

Last Friday a gastroenterologist complained at the hospital lunch table that the Dallas Morning News ran a commentary that physician fee for service should be eliminated and all physicians be salaried. Not long after, at the end of his break for lunch, he got a call from his office about someone he had never seen who had a proble. The GI told his office to work the patient in that afternoon, somewhere on the schedule. After he hung up the phone, his comment was that without fee for service, the patient would find it difficult to be seen by a physician that Friday afternoon. What do you think?

Agree for the most part with DOCLMG. I am already on salary, but it is negotiated at the local level. I don't think most physicians should be salaried. Howard Dean is a far-left wing idiot.

Physicians should be free to decide, like any other US citizen, wheather they want to work for salary or on their own. Simple as that.
This is democracy, unless we are in for a surprise.

I worked for a salary when I first started out by doing my National health Service Corps obligation. I worked in a clinic where the administrative head, and my immediate boss, did not even have a high school education. He employed every single one of his relatives in the administrative office. They went on lavish trips, repaved the office parking lot every year, had new cars at government expense, etc.

Meanwhile, I received the same salary that the physicians who did no hospital and worked five days a week, monday through friday, did. The idiot boss tried to say that I actually worked part time, in that I was not in the office on the days when I had to be in the hospital to run pitocin or do surgery.This was while I was on call every other night and every other weekend. I threatened to phone him every hour that I was in the hospital in the middle of the night to keep him updated on my work status.

So, work for the government????? Been there, done that, don't want to do it again.

I will take a salary. Pay me the same as a US Senator. I will even work a 40 hour week (unlike the Senate). Plus I won't ask the tax payers to pay for my incidental living expenses.

What people like Dean want is to make primary care physicians paid the same as school teachers. Surgeons will make the same money as good Mercedes Benz mechanic.

Stop pandering to the malcontents amongst the MD group; take a stand on more substantial issues that improve coverage adn care delivery. YO uare jus texploiting the unhappy verbal docs.

why should physicians be salaried if wall street is not salaried and why should we have to accept this health care plans when congress and the senate have different health care plans and social security benefits. This system will make it more difficult for access to physicians, of note why see and squeeze in patients if we are all salaried.

We could be salaried. That would be fine. If it were to happen, I think it should be applied to all professionals though. Why should we be singled out? Also our costs should be passed on to those who are paying our salaries, including our school loans etc. Our work weeks should be modified. I'd like to clock out at 5. Weekends would be out too.

Attorneys should be salaried. CEO's should be salaried. Stock traders should be salaried. Politicians should be salaried (and book deals/royalties/bribes/other perks rolled back into their employers coffers). Small business owners nationwide should be governmentalized and salaried. This way we can be absolutely certain there is no funny business going on anywhere.

I can't believe this is being suggested with a straight face by a major politician in a free market economy such as ours and then not treated with complete shock by the American population. What have we come to?

I am on salary and it sure works for me, especially as I think I do what procedures and tests are in the patients best interest, without worrying about how it impacts my monthly income.
It sure sounded to me like our very own Dr P dodged that question, as much as Dr Dean. Probably because he knows there are a lot of physicians out there - military, VA, academia - who are paid a salary and are quite happy with it (In fact, I argue that from the standpoint of trauma and emergency surgery, no other arrangement makes sense).
If you want to go out there and be an entrepreneur, face declining reimbursement and increasing overhead every year, and likely work yourself into burnout just to keep up a decent income and lifestyle, well, that's your choice and it should remain so.

I would welcome some form of salaried system. Myself and many of my colleagues are increasingly frustrated about how difficult it is to make ends meet running a practice. I left my practice after 5 years to avoid filing for bankruptcy. Since then, I only do locum tenums work. The stress level is gone but I still don't feel that I am paid appropriately for the work that I do. I tend to hear more opposition to healthcare reform from the generation of doctors who began practicing in the 70's and 80's. What they don't realize is that the current generation of doctors is struggling and becoming increasingly disheartened. We need a change!

I think the 6 question posting was constructed in a way that promotes dissent from any healthcare reform. I didnt see options, other than "other," which would allow my enthusiasm for change to show. I did see plenty of ways to voice a "resistance to change" opinion. Thumbs down to Sermo for not making a neutral polling. I think that's referred toas a type 1 error in research. They want to "find what they're looking for."

It would be a terrible idea and finally it would hurt patients.
Doctors are good people, not saints. Which doctor would squeeze those extra 2 patients knowing that they will have to skip their lunch to see them? Which doctor will add a patient at 7pm missing dinner with their family if they will earn the same as the colleague who works 9 to 5?

Salaried to whom and for how much? The CEO's of our mega-hospital systems are often drawing down multiple seven figure salaries. If they are MD's, will their salaries be cut to politically correct levels? Will MBA/MHA's be allowed to continue with the high salaries?
How about private practice Midwives? Dentists? Will Oral surgeons be included? Podiatrists? Chiropractors? Hearing Aid Dispensers (licensed in my state)?
Howard Dean has truly exposed himself for the shallow thinker that he always has been.

Hey Howard - go F*$*()$ yourself. Last time I checked, the 'salaried' guys at the non-profit were making 7 figures irritating docs and reducing the quality of care at the hospital by interfering with physicians trying to do the best they can for their patients.

Whoever pays my salary controls my life. Currently, that person is ME. Do I have to answer to some f*&*kstick who knows diddly about my practice, or how to compete and build a practice, or who knows a damned thing about medicine in general? Administrators should work for us - lets have a new policy.

Lets make physicians required * to own all hospitals, all clinics, and so forth. No non-physicians are permitted to operate healthcare. Let us run it as we see fit and then modulate what you pay us based on a non-CPT based system.

Try that on for size, before you attempt to socialize medicine.

I'm salaried because of the Government and the lack of reimbursement after 15 years of struggling to make ends meet in private practice. I'm working hard enough to be challenged and fulfilled and provide a substantial service but do know that being salaried does not induce me to improve access or solve the crisis. Make it financially worth while and physicians will solve the crisis. Let capitalism run health care and get the government out and we all will find ways to succeed and prosper based on supply and demand.

(nausea)

Freedom to make the decision to be salaried or not should absolutely and unequivocally remain with the physicians - or any other person for that matter! I choose to be employed by a small rural hospital. I've been in private practice. My choice was dictated by the needs of myself and my family.

Government involvement has continued to be proven historically to be an incredibly inefficient process. Far more money will be wasted in the inevitable bloating of the health care bureaucracy. That should alone scare the public. But Obama's message is telling those "without" to take from those "with"...a very enticing message in these troubled times (that he has frankly worsened beyond belief).

Howard Dean is an obvious left-wing shill. The reason he doesn't care is that he makes his money in politics now. I can't imagine a REAL LIFE doctor wanting the government to dictate his/her salary...crazy!

That my $0.02 anyway...

Random thoughts from an old retired surgeon.
I'll bet British and Canadian docs don't worry how much to charge for a procedure or overhead costs. .
Dan, you have morphed from an organizer and accelerator to an outspoken advocate. Are you bucking for some high office?
Doctors have to realize that this is a fight for survival and profits by health care insurors and drug companies. We are pawns, and should not be helping them. Look at all the "health care dollars" that are being spent to prevent change--over $3 million to six senators on the committee, $85 million annually to the top 10 health CEO's, one million a day to lobby congress. That's where your and my health care dollars are being spent.

And one more thing: the only guys who love salaried positions are those who would otherwise have to work harder to make the same or more. Those specialties that are required by a hospital to be in place (say, general surgeons covering ER hmmm?) are subsidized by higher earning docs who are stupid enough to accept 'salaries' e.g. radiation oncologists.

The context of the physician's salary is even more important than the mere instituting of "salarization". It would be a serious reform if the government and other interested groups were to foster the development of multispecialty groups that

1. consisted of salaried providers
2. acted as an medical insurance plan, competing with other such groups
3. bore the entire medical liability burden for its providers, thus fostering, on a systemwide level, some serious cost-benefit analysis of healthcare practices.

It needs to be recognized in all this debate that real change opposes not only various vested interests but also BOTH the lay culture that expects to get an MRI for a headache and the professional culture that thinks it's a good idea. This will take a bit longer to change.

Please, please salary me. I would love a hospital to buy my practice. I would be working fewer hours, getting a steady paycheck (am behind 2 paychecks this year so far just so the staff can be paid) and be paid for vacations. I would love it.

Not the worst idea in the world, but it won't solve all the cost issues.
The most expensive part of medicine is hospitalizing patiients and the big bills don't include drs fees. So what should be done is price control, not salary control.
The other issue is pcp's barely get paid as it is. If you want more pcps, leave them as they are and salary speciaists only.

I was a flight surgeon with the USAF for ten years following which I practiced family medicine as a civilian for 23 years. During this time I have come to respect the concept of salaries for all physicians as an important part of health care delivery. No doctor should get rich on heath care. Any doctor doing so just on health care income is seriously overcharging and "milking the system". One should expect a reasonable return on his educational investment but never expect to become a millionnaire. I see no problem with salaried physicians.as part of health care reform.

Dean could not make it in medicine thats why he is trying to bring it down

I am so laughing at this.

In primary care, as much as I hate having to crank out the patients due to poor reimbursement, it definitely helps access. I've got a buddy at a local HMO who sees 12 patients a day, and he is older with experience so he is at the top of his pay schedule. Patients have to wait 2 months for a physical.


I almost hope this happens. I would love for people that think this is a good idea to call their doctor and try to get in for an appointment. "Sorry, you have a sore throat. We are booked until 2 months from now. We see 15 patients a day and we leave at 5pm. Go on down to the ER."

ER calls with a patient they need to get in for a follow up within a few days. "Sorry, we are booked out a few months. "

I hope the idiots get what they deserve.

Salary = effort.

If I am forced to work for salary then I become a laborer....not a professional.

I will determine parameters of salary and work within the framework. No more. No less.

I will seek to unionize. If it is good enough for GM, Federal Employees and VA...then, as a salaried employee I will expect the same.

Although I enjoy my radiology practice,if my income is not productivity driven then my efforts will be directed toward other areas in my life which continue to yield benefit in relation to effort: my marriage, my family, my hobbies. I will make do with less monetary income and enjoy more emotional benefits.

I will not beat my head against the wall of political buffoons who think that physicians work solely for the "love of the vocation"...those days disappeared when trial lawyers, insurance companies and demanding patients became the norm.(I need my MRI NOW!!! and I don't want to pay the copay of the insurance that I have)

I like being on salary because:

A. Reimbursement for Primary care is so ridiculously low I make more this way.
B. I am lazy and find patients to be needy pests.
C. I am too afraid to do something myself.....

Are there reasons why physicians can't create our own "insurance option" to compete in this new market place?? I currently work in a hospital which has an MD as a CEO. It makes all the difference in the world to have an MD who has practiced clinically stearing your professional organization. I would like to see a physician owned mediacal "co-op" on the market place. Although I would assume we would be slapped with anti-trust litigation.

No doctor needs to make more than $200,000 per year based on a 40 hour work week, 4 weeks vacation per year, standard productivity (if you see 100 patients in 40 hours, you'll still have to see that many), expenses paid, and bad debt deductible. Then we might see med students actually return to primary care from the lucrative and excessively paid surgical subspecialties and medical procedural specialties, to where they are truly needed by patients. We don't need heart transplants or a gazillion colonoscopies, we need blood pressure and diabetes prescriptions and checkups paid for. And all doctors should be required to donate at least 10% of their professional practice to indigent care (unless, of course, everyone finally gets insurance). Indigents and the working poor without insurance deserve care too, and the richest doctors (and dentists) are not providing it.

Howard Dean is just one more from among that group of physicians who don't regularly see patients, and who's narcissistic motivations drive them to adminisrative/policy positions in which they can assuage their need to 'be important', control other peoples lives, and avoid those parts of medical practice, such as nightime call, that they are in actuality too lazy to handle. That's about as gently as I can put it. I can't imagine having a conversation with Dean that wouldn't bore me to tears within minutes. He's a lightweight, and is entirely misinformed.

We are historically in the most rapidly evolving period in biomedical science and therapeutic development, and our nation is a world leader in these areas. The private sector, and the capacity to prosper on the basis of one's efforts, in addition to doing good, drives technology development. All that the current approach to 'reform' will do is stagnate this rapid progress, deal a signficant blow to biomedical science and technology development in the US, and ultimately markedly decrease quality. To think otherwise is sophomoric, at best.

With regards the hope of the academic community that a more liberal approach will translate into greater research funding, this is a precarious notion. When the inevitable cost overruns of a government run system come on line, the NIH budget will most definitely take a significant hit. in addition, those studies that are funded will be targeted to things like outcomes analysis and public health studies, not necessarily basic science.

I work for a community health center, am on salary, have my loans repaid for me, work a great schedule, and get to actually see my family on evenings and weekends. For Primary Care, it works.

I agree with most of the above. I also agree with Dr. Daniel Palestrant but I think he is not ready to be on national t.v. I was embarassed watching the CNBC debate.

I have the sinking feeling that I voted for my own demise last November...

I thought he did a damned good job of calling out Howard Dean on his two-faced typical liberal approach to solving the problem. Good job, Dr. P.

The salaried physician, without financial incentives (currently in the fee for service model) will turn the medical professional into US Postal Service employees...run like the VA hospitals, which have a very high price tag, and deliver poor care (just look at their record). Salaries will be the quickest way to de-incentivise physicians. When the clock strikes quitting time, the docs will leave..and the waiting patients will wait some more. No physician will get out of bed in the middle of the night to come to an ED...rather, they will "put the patient on hold" until the morning...unless it is a holiday.

Salary? Ok, how many weeks vacation????I'm out of here! Hello 8 hour day, goodbye emergency patients! The ones to suffer will be the patients. But then again, I've never heard any concern for them thoughout this discussion. Only how to cut costs. With the baby boomer getting to medicare, did anyone consider that Americans may WANT to spend more on health care. Say, more than on Iraq?

My old grand paw always had one piece of advice for me: you always get what you pay for!
Sorry, but I did not spend the best years of my youth to become a government minion, mindlessly following some treatment protocol approved by non physician bureaucrats in some ivory tower.
Sorry, but medicine is too damned important as a profession to allow government to run it................period. We seem to forget that the government is supposed to be OUR servant as citizens, not the other way around.
Sorry, but until the legal profession becomes socialized, any attempt to allow them to socialize medicine should be unceremoniously thrown in the fire..............
Sorry, but no plan, no agenda, no legislation this important, this long ranging should be enacted UNTIL the people have a chance to read it and understand all the inherent demands that it will place upon us, the citizens.
Sorry, but I do not believe it to be constitutional to take away my rights in order to give others more rights.................
Sorry, but I cannot drink this kool aid..........and still fell that I am a FREE American............
Sorry, but should the little bas*ards in DC allow this to pass and ACORN to take over the practice of medicine, I will lead the charge in my state to secede.............for their Amerika is most certainly not mine.

I think it would be helpful to keep an open mind. The status quo is unacceptable unless you're rich. Something needs to be done. It's silly to criticize someone when they're the only ones with a proposal. Nobody else has anything.

Bring it on baby. I am nearing retirement. Currently I work about 100 hrs a week and make less per hour than my PAs. Salary will be for 40 hr wk and no holidays, no nights, no weekends, plus all the benefits. Maybe work less but get more per hour and no hassle. Who knows, maybe I can work 2 jobs, make 2X what I make now and still work fewer hours. Or maybe, I will go with doctor friends to a little island to the Southeast of the US (outside the US) and set up our own clinic and take CASH only.

salaried employees have no incentive to work more or harder. period.

while salary would fix some problems it could overly dis-incentive physicians as well. where would the motivation be to see one more patient urgently who needs to be seen and where would the benefit be for those practicing higher quality of medicine. it would certainly be better than the current system with so many different insurers each having different forms. i suspect that my life would be a lot better if i could ismply take care of patients and not worry about all of the paperwork i do now. i think salary is worth looking into but should have more practicing physicians weighing in on the questions.

This is not pandering. It is an effort to stop the propaganda. Socialism has three parts: those who need, those who give and those who decide. The deciders get ahead by obfuscating.

In my opinion, HR 3200 is an earnest effort to salvage managed care, a failed model.

Deciders who decide how much to pay physicians will trump. Buzz words like "improve access" and "physician run" means I will work for bureaucrats, not patients.Physicians on the management side - IPA/HMO/PPO - see HR 3200 as an opportunity to Kaiserize the rest of us.

amdcu93 and evolutionary, is salary really your only incentive to work? don't you think your decision to see fewer pts solely to protest being salaried might make your employer want to hire someone more productive than you? (surely keeping one's job is an incentive). Or maybe decreasing your pt load from 30 to 10 per day would be a good thing -- allowing you to provide better care without worrying about paying the bills.

Practically, the idea of all physicians being salaried probably poses insurmountable obstacles (e.g. in rural areas, as noted by wsugaimd), but theoretically, I'm all for it -- I do not want to be a businessperson, and have to admit I'm a little skeptical of physicians who do.

This one comment stream is probably the most important I have seen on SERMO in a long long time.

As a citizen of this country, I believe that government should be responsible for security, education, and healthcare derived from our taxes. this said, perhaps we should move to a more socialistic form of healthcare similar to western european nations. However, as long as insurance companies exist and generate profits based on healthcare cost restraints and reward their investors with high dividends and allow unreasonable salaries to higher management, then in no way should we even begin to consider becoming salaried! The insurance companies as well as the GOP/right wing are touting the free market as the way to correct this mess. Although not a proponent of this path, if so chosen, then the free market should not only allow the insurance companies to determine what services they will offer the public at what price, but also physicians who have been blocked from similar to mandate to the insurance companies what their services are worth, and negotiate from that point.

If we are salaried by the government, it means that we are government employees.

Therefore, we should get the following:
1. Sovereign immunity protection from lawsuits
2. The right to unionize, collectively bargain, and strike
3. Full government benefits (maybe we'll get to opt out of social security like Congress does)
4. 9-5 hours and paid vacations
5. Workers' compensation
6. Licenses and CME paid by Uncle Sam
7. A neat little ID badge

And we will have the ability to provide healthcare as well as the VA (which Gov. Dean and his guest touted -the next day on MSNBC- as providing better care with a higher satisfaction rating by patients than the private sector. Has he ever been to a typical VAMC? I'd love to pick apart that data!!

Wow, what a powerful article: Thanks to andrewldoe above. www.theobjectivestandard.com

If most of you accept Medicare, why would you not accept Medicare-for-all, which is the model proposed by the PHYSICIANS FOR A NATIONAL HEALTH PLAN (www.pnhp.org) ? It is basically fee for service.

About a comment above that 1/3 of doctors in Briatan are foreign born...how many of ours are? (including myself)

Physicians paid salaries by institutions that make money on the physicians' practice of medicine........as opposed to physicians making money on their own practice of medicine. Institutions focus on the bottom line...or the dollar, with patient care being only a part of their buisness. The practice of medicine by physicians is less of a buisness and more of a calling. Patient care is paramount, while the buisness of medicine plays only a small role. The role of the dollar in private practice is small but important to sustain the costs of a practice and for personal reasons like loan repayment etc.

DAN stood UP GREAT to an Experience Politician! Yes I watched the salaried Docs at the VA.. cushy jobs.. and when cut backs We were told to tell the VETS that what was missing was NO LONGER TREATMENT OF CHOICE..even tho it was the Cancer treatment that WAS moving people into REMISSION..

Also, In MIAMI, i have never forgotten how one of my patient's son who worked at Miami Va finally left to go into PRivate PRactice as he could no LONGER JUSTIFY WRITING RESEARCH Papers with Outdated Equipment that was better on the outside>>!!!

TRUTH IS THAT PRIVATE MONEY IS WHAT BUILDS BIG AND STRONG CHURCHES AND MEDICINE... All FOUR FORMS of USA GOVERENMENT MEDICINE are in FAILURE AND collapse ..!! It is LEGAL MEDICINE and COST SHIFTING from GOVERNMENT MED to PRIVATE that is cost of escalation of Premiums for PRIVATE Insurance!

SALARIED DOCS AS GOV PROGRESSES will NOT be as they are NOW!! The GOV will NOT have PRIVATE standards to compete with..

DO you NOT know that Medicaid in NY state pays 34 cents for what we charge other patients $26? Now, in NY state it is a game of LET'S CUT COSTS by DECREASING Payements to YOU KNOW WHO !? the DOCTORS! In this STATE AND failed Mass. of Ted Kennedy.. NOTICE how the PEOPLE are HAPPY TO CUT PAYMENT TO DOCS>> NEVER TO LAWYERS

so IF SALARY GETS GOING FOR us and not everyone else, trust me, the Medical Folks in MY FAMILY WILL BE TRAINED TO USE THEIR GREAT BRAINS and STRENGTH Part time in Medicine to no time as they evolve different careers!! NO OBAMA SLAVES in MY FAMILY! We helped build up this country NOT OBAMA style to GIVE away our borrowed money to Mideast, IMF, UN, Planned parenthood international, Europe including Germany, England and FRance who also gambled with derivatives ON THEIR OWN! OBAMA "S goal is to destroy the USA as payback for what my family, as part of the NORTH , did to correct Ancient European & mideastern slavery. call a spade a spade! if you can!

Bodomo you are right on the mark, that is the fact that Obama and all the other politicians do not realize when they compare our healthcare system to other countries. The current administration has no idea how the proposed changes to healthcare will affect medical school admissions and the quality of individuals seeking a career in medicine. Although we all are in this profession to help others none of us signed a vow of poverty. With rising costs of Medical Education in this country, and a push to limit our ability to earn income, I fear this system is headed for collapse. I recently finished eight years of surgical training and have over 100K in loans, I fear that the current administration threatens my ability to ever pay those loans off. The Discussion about healthcare reform should start with increasing healthcare coverage, but must include some reform to eliminate the burden of medical education in this country. Sure I'll take a salary the day after my loans dissappear until then I have no time to listen to Obama, I am too busy trying to earn a living.

Maybe we should get Howard Deans salary and be allowed to see Lobbyist as well to make up for the scraps they want to pay us. We need to speak up otherwise wewill have absolutely no say in the way we practice medicine, we may need to unionize to have our voice heard because right now it is fragmented with public opinion that the AMA speaks for us

Sure., it is possible. We all make $240/hour ( equals 500K for a 40 hour work week) and cannot be sued - the government is the defendent unless the case is criminal. There are baseline quality and productivity standards for each specialty - determined by the specialty. We have pension plan just like those in Congress.

Obama's motto should be "Trillions for bailouts and banks, not one cent for healthcare".
Why is it that he says healthcare costs are bankrupting this country?? He already caused the bankrupcy by taking over $24 TRILLION dollars of bad debt from AIG, the banks, etc from the derivatives and real estate mortgage mess--that's right $24 Trillion (it boggles the mind). That money is separate from the $1 trillion TARP funds and loans given the banks just to keep them from failing. Now the banks and brokerage firms are paying out $700,000 bonuses to its employees--the highest EVER. In my opinion, any profits made by the brokerage firms, banks etc should be taxed at 90% to pay back to US citizens and to pay for health care. Why is noone talking about this??? Why is Obama not targeting those bonuses?? That's what someone should ask him at one of his staged town hall meetings!!!

Agree with StilllearningMD. We can't afford to react to each sound bite and fail to act on the bigger picture.

Dr Dean needs to be on Haldol.

Pet Peeve

Nobody has pointed out to the public that when we get reimbursed by the government the payment paperwork indicates that the agreed upon value of the service is X then it states the payment is e.g. 60% of X. X being the usual reimbursement by non-government insurance companies. This unfair advantage is one of the reasons the government will help drive the private inurance compaines out of the market

Wish we could do that with Malpractice or Income Tax ;)

We know what the best practice model is for medical care. It's an integrated, not-for-profit group practice or HMO-style arrangement, like the Mayo Clinic, where the physicians are on salary, involved in clinical and administrative decisions, and provide a medical home for the patient. These consistently provide high quality care at a lower cost.

I would modify Howard Dean's comment to, "Most physicians should be on salary." There are some exceptions--like the isolated rural physican--but a streamlined, not-for-profit system would help everyone. One of the dumbest things we did in this country is shift from a non-profit community hospital system to for-profit hospital chains, surgery centers, etc. over the past 30 yrs. While this may have improved access in some areas, it has resulted in much higher overall costs and lots of unnecessary procedures. But it's made some people a lot of money.

What bothers me most about all the reform plans is that I see no proponents for medical savings accounts combined with high-deductible catastrophic policies. This would do more to help reign in costs than taxing health insurance.

If it were up to me, I would have:

1) High deductible (suggest $5,000 per person, $10,000 per family, adjusting upward with inflation) catastrophic insurance medical and dental coverage by diagnosis--not calendar year--either individually purchased or via employer but with after tax dollars either way. Standard minimum coverage and limits set by an independent government sponsored agency--something like the IOM--based on best evidence available for effective therapies. Standard co-pay percentages or dollar amounts by type of service. No preexisting condition exclusions, but no blank check for people with likely poor outcomes either, except if they enroll in an approved clinical trial. (If you get a diagnosis that's uniformly rapidly fatal, you get palliative care covered, but no heroics.) And nobody gets more than $2 million (inflation adjusted) in total coverage for any DRG. However, if you get a chronic disease, like diabetes, after you meet your initial deductible, all further evidence-based care is covered for life, though with the usual co-pays. Patients would have the option to spend their own funds if they wanted something more, however.

2) Pre-tax (suggest up to $3,000 per individual, $6,000 per year per family per year) medical savings accounts for all routine medical and dental care, with patients paying directly and up front for most routine or acute care. Account could be drawn upon with a debit card, to facilitate collection by providers at point of service. Accounts could carry over from year-to-year and grow up to $50,000 per working individual, $100,000 per family before tax break was lost. Allow upward adjustments for inflation. Allow up to half the existing balance to be transferred (donated) to another account.

3) Government covered $0 deductible cost-beneficial preventive care - all immunizations, well child care, smoking cessation, Pap smears, colonoscopies, etc.

4) Government subsidies for 1) and 2) above for the disabled and working poor. This might be in the form of direct subsidies or via government run clinics and hospitals where service was provided at reduced rates. Everything on a sliding scale, with all subsidies being phased out entirely at 2-3 times poverty level.

5) Higher taxes and penalties for unhealthy behaviors - cigarettes, junk foods, riding motorcycles without a helmet, drunk driving. You want to be stupid, it's your life, but everyone else doesn't have to subsidize your stupidity.

6) A play-or-pay mandate for both employers and individuals, so that people can't get a free ride on the system at someone else's expense.

7) Tort reform, with limits on noneconomic damages in malpractice awards and with proper provision of evidence-based care being an affirmative defense.

Any takers?

Anything run by the state opens the door to fraud , lack of quality and extensive birocracy.
Why do they pick on doctors ?
Why are not the lawyers paid salary .
Why do they wany price control on health care , when nothing else has price control?

This proposed plan just will not work. The American public feels entitled to the best, most advanced health care available, and want immediate access. As technology costs and staffing costs and malpractice expenses rise considerably, reimbursemsnts steadily decline, and efficiency peaks, there is little profit in the system. I can't imagine the beurocratic bloated US Government being part of the solution. The true colors of the legislators ( the majority of whom are lawyers) is exposed by their intransigence toward reasonable tort reform .

salarying doctors - in ALL socialized systems - leads to the worst level of care. Why do think so many foreigners come to the US for care?

it doesn't matter what doctors think. It is the loud cry of the voters and public opinion that this country has the image of the worse health care for an industrial nation. The medical profession is doomed. There has been so much outcry to "change" that the congress cannot take the pressure and all the die hards are folding like cards. When SERMO was represented during the meeting with Howard Dean the news anchor woman didn't even know what it was. We are a silent voice regardless the number.
Daniel Palestrant, MD did an outstanding job representing the doctors but I do believe that Howard has his ears on upside down. I don't understand how a governor is more privileged to knowledge about the healthcare than the very ones that are the backbone - the doctors. I fear that the congress is like Nero who was famously to have 'fiddled while Rome burned'. Nero's lust and lack of self-control lead to destruction. I fear history will repeat itself.
Best wishes to Daniel for his constant fight for all the doctors and patients.

Nobody should work 80 hours a week on a regular basis - not good for you, your family or your patients. No one should have the right to do that or an obligation to do that anymore than a jet pilot should fly 80 hours a week. There won't be enough primary care doctors unless medical school tuition is paid. Professions that provide essentials ie farmers, doctors, nurses, teachers are special cases and the higher your job is on Masslows hierarchy (breathing, water, food, shelter, nurture) the more limitations there should be on price gouging. Why do I (med-peds) make less than ophthalmology etc? Some people on salary are slackers and some are hard working. Having a salary does not preclude bonuses (see wall street). I have run my own practice for eleven years and now I am employed and both had advantages but employed may be better for patients. Being salaried is a characteristic of many of the systems with the best outcome with lowest costs ie IHC, Cleveland and Mayo Clinics. This is just part of the picture of our broken system.

Salaried positions work for some people, and that is fine. If you wish to be an employee, no one should look down on you for that. HOWEVER, to mandate all physicians to be employees of the State (or State supported organization) is Socialism. One thing that history has shown us is that free market economies improve the quality of life of the whole populace by allowing entrepreneurs to work harder to make gains for the common good as they help themselves.

LLerner:
"I have the sinking feeling that I voted for my own demise last November... "

P.S. Yes you did.
P.P.S. I do blame you. Next time go beyond the slogan, and do some research....

The VA/Medicare and Medicaid have set the industry standards for world class care at this point. Get your meds refilled in the ER for FREE!!! Get a CT scan for your 7yo that fell off the bed and is showing NO symptoms. We can get $10,000 tongue depressors.... I wonder what the weather in Australia is like or I might go get my plumbing licence.

cannot answer all the questions.Retired.
I have some experience on government intervention: instead of bringing England and Canada as example of socialized medicine, why the interested parties do not study France and Italy (number 1 and 2 on 'delivery of medical care' -WHO Summary 2007)?

To keep and attract the best, the government may have to allow a gov.salaried practice and a limited private practice. Will this diminish the costs? Possibility of two tiers of medical delivery; one for those that can afford and a second for the remaining citizens. Will this solve our present problems?

Being on salary certainly is not appropriate for everyone. I am a salaried employee of a hospital system. It definitely has its pros and cons. Agree with above...no incentive to work harder. Get paid the same whether I see 10 pts or 50 pts per day. Only issue is..if I don't produce, I could be fired. It all depends on what your needs/wants are. Being salaried works for me right now. I've only been in practice 5 yrs and I am in a more rural area. I couldn't make it in my area doing peds by myself...too much medicaid and vaccines alone would bankrupt me. I'd have to move somewhere else, which is not an option right now. With that being said, I do NOT agree that all docs should be on salary. That's ridiculous. If all docs were on salary, access to care would decrease regardless of whether more people had coverage or not. No one forced me to be an employee...I chose it this way and like knowing that I could choose to go on my own if I wanted to.

We already did this experiment in the mid 90's in the private world. Hospitals bought practices in anticipation of Hillary Care (or is that Obama/Dean Care version 1.0) and put the docs on salary. Everyone knows what happened - hospitals closed practices like crazy to avoid going bankrupt as no one worked as hard - its just like public school teachers - salary without incentive = less work for more pay and benefits with worse outcomes. LOL!! That's change I can believe in.
Everyone also knows how Canada works - you basically get your "salary" in advance - and when the money is gone, Canadian MDs head to Fla and hang out the "closed for vacation" until the next years allocation is available.
Anyone who can't see this is Socialized Medicine is being purposefully blind or a fellow-traveler.

Another thought to add to my rantings above.....................you know folks, we have the biggest dog in this fight...............US......................without US there can be no health care...................what are they going to do if the majority of physicians in this nation just says 'NO".....................arrest us??? Tax us even more???? Force us into indentured servitude...............wait, that is what they are wanting anyway.
WE HOLD THE ULTIMATE POWER IF WE WANT TO GROW A PAIR AND USE IT..................SO LET US USE THIS POWER...............we do not have to to bend over and take anything................a few weeks with half the doctors not practicing and the public outcry against Congress would be deafening.................

Dean's statement is as non-sensical as saying: all lawyers should be on a salary, all CEOs should be on a salary, etc. There ARE MDs who are on a salary now b/c the market has determined there is a need for that and some MDs choose to be on a salary. Let the market determine if physicians are salaried just like we do with accountants, lawyers, et al.

Not Dan's or Gov. Dean's fault. That debate wasn't set up for anything more than a quick CNBC soundbyte. Very superficial and disappointing. While I disagree wholeheartedly with Dan's kill the AMA thing, I certainly applaud his courage and forthrightness on behalf of those of us still in practice. Gov. Dean is much like so many former doctors who go into administration or government who quickly loose sight of tyeir roots. Salary? Been there done that with the Public Health Service and an HMO. What a way to wreck initiative. OK for some specialties (ER, trauma) and some temperamants, but most of us choose medicine because were different. Private practice is and always will be the best fit for me and my patients and should not be abandoned in some misbegotten rush to extend, standardize and dumb down our health care system. We will surely throw the baby out with the bath water and end up with a government administered rationing with the same unrealistic expectations from our patients and courts.

This was a biased survey.
I work on salary in a community health center, and enjoy the freedom from worry about malpractice or overhead.
I can concentrate on providing quality care for my patients, with incentives designed to provide better care. I get my base salary, then get paid more if I see more patients, and reach benchmarks in patient care. This makes sense to me.
I don't see salaries as an evil thing that makes doctors lazy.
How about salaries plus bonuses, like the financial system?

And to think, I committed 4 years of college, 4 years of medical school, 4 years of post-graduate training, board certifications in 2 specialities, students loans in the 6 figures, countless hours of on-call time, CME's, tens of thousands of hours of community service, an occasional moment of stress from working in a high risk field, being responsible for the lives of others, founding, launching and sustaining a successful private practice, time away from my loved ones, etc., etc. WHAT WAS I THINKING? When I could have been a salaried government employee with little stress, full benefits, and taken a job at the post-office or elsewhere?
Aside from the deep personal satisfaction and passion i have for the Art and Science of our field, coupled with the ability to help others... I GUESS I BLEW IT!?

If a UK model is adopted, overhead expenses are paid and the physician has a predictable income. In England, there are outcome based financial incentives that have improved health outcomes (US ranks 37th by WHO criteria). If you watch Sick Around the World, you will see that primary care physicians are compensated better there than here, increasing the number of PCPs and thereby access. They serve as gatekeepers, preventing unnecessary referrals and treating conditions before they require tertiary care, reducing morbidity and costs. They are allowed to function as doctors, rather than businessmen.

Physicians would need to be heavily represented in the decision making process in any single payer system. Since we cannot avoid changing the method of funding now that the insurance industry has declared itself at imminent risk of insolvency, we should take advantage of the opportunity to create a system which affords universality, cost controls, outcomes-targeted interventions, elimination of wasteful inefficiency and a stronger role for the physician in determining what is best for the patient and society. This can only be done through a single payer system, as every other democratic and economically stable country has decided.

In a government-employee model, it would be simple to impose tort reform, as malpractice award limits are in place for federally employed physicians such as myself, as they were when I worked for the County on a State contract.

A single payer system does not eliminate the provision of private care, which would be an important stopgap while the new universal healthcare infrastructure is built up. Private care will continue for those who can afford "Cadillac" policies and choose to use them, much as people send their kids to private schools if they so choose and can afford to do so.

Rick Staggenborg, MD
VA CBOC, North Bend, OR

I think if this is what the President and a Democratic Congress want,they will reap what they sow i.e. socoialized medicine with rationing of care.No PSAs in men over 65,limitations to ESRD/tranplantation above an established age, no colonoscopy after age 70,no CABG,PCI or valve replacement surgery above a given age,just to name a few.Their needs to be a change but I doubt that it will be motivated by the "spirit of liberty and revolution' that spurred on our Founding Fathers.I think it will be driven by envy, self-serving agendas, and God forbid, and brokered deals of what's in it for me and my constituents.

I am okay with a salary for medical care providers as long as it is commensurate to a physician's (or any other care provider's) training and experience. The ideal model should also include some productivity bonus, outcome bonus, efficiency and/or gainsharing bonus. This is the best way to limit the costs within the healthcare system.

I do not believe healthcare is insurable. Because of the large sums of money required for care, insurance companies will always have the power to do whatever they want such as pay their CEOs millions of dollars for essentially creating a complicated system that denies care and/or denies payment for care. Additionally, individual lifestyle is too intertwined with health. Individuals should have the option of managing the problems they created for themself in their own way. A base plan should be provided to all Americans without cost, with the option of creating a tax free health savings fund to pay for medical stuff. Just like an IRA, the money could be available for non-medical stuff, but there would be a penalty. The base plan should include immunizations, well checks, OB care, preventive care, generic meds, x-ray and cheap medical supplies (i.e. a cane, ACE wrap, etc . . .) Beyond that, you're on your own.

We should do it contingent on all bankers, money managers, and stock brokers doing the same and doing it first.

In the future, salaried MDs could make medicine a decent job (no longer a profession) but only if the government (or whoever is paying the salaries) pays for the cost of a medical education, covers the MDs' liability costs, and pays the overhead. Like any other business, if you remove incentive, service is going to suffer. The question boils down to whether health care is a right or a privilege. If it is not a 'right' then the government has no business being involved. If it is a 'right' then the 'providers' should not have to bear the cost of 'providing' it. No government employee works 60+ hrs a week. Take away incentive, I won't either.

I would love to be on a salary. It would reduce my workload tremendously.

I worked for a large group where the physicians were paid salary when I was first out of training. You never saw a lazier bunch in your life! On salary, specialists see everything as a "primary care problem". I left there to go solo, see fewer patients, the specialists take care of specialty issues and I make twice as much!! Where did all that money I was generating go? Apparently to the salaries of the specialists! Without the incentive to get paid appropriately for the work one does, the incentive is to do less. I don't want to ever work for someone who tells me how much my labor is worth. I don't mind working for the local IPA that takes capitation and pays me FFS. If I don't like their FFS rate I can drop them. And if I stay late, admit a patient after hours, see more patients in a day, I get paid more. The way it should be in the USA!! God bless America!!!

I will agree to be salaried at +200 $s / hr and and CAP on the number of patients I need to see per day at 15 - and maximum 20 . so that quality will not suffer !!

Issorbm, the WHO is far from unbiased.

Also, France and Italy are beginning to see longer and longer lines for care. I bet you won't see another WHO study about this until we either socialize, or the WHO becomes objective.

Again:
Sermo Doc

Dan,
I wish you would have pushed him on this issue. The key question is "Who is going to be paying doctors salary?". The answer if Howard Dean and the proponents of big government are in control is obviously the government. That just means that the government would take over the entire segment of small businesses in America that provide medical care. I think we all know that is a bad idea. The other option is for the largest hospital systems in a given area buy all of the private medical practices. Based on the experience in the 80's, I think we know how this turns out. Either way, the proponents of "salaried physicians" clearly have not thought through the ramifications. President Obama loves to say how good the care is at Mayo Clinic. While no one disagrees, trying to use that model for the entire country is nearly impossible. Obama clearly does not understand how health care is delivered in most of the country.

Ill pay for Howards Dean visit to China, Eastern Europe... and learn some ABC's of medical practice!! Simply tOOOOOOOO myopic, short sighted!!

Howard Dean protrayed himself out of touch in medicine! Granted the government (employer) has the money to support a "communist system of salaried physician employment " , the professional motivation to succeed and be the best further is gone!!

Remembering that we have different aspirations, work ethic, convictions, independence, accountability, etc. etc. etc.

1. Many of us have been salaried before and simply some are fitted to work, others just want to check in, hide somewhere in the closet, take snack every 15 minutes, PROCRASTINATE till the next shift (its time for my paucheck mentality!!!) ... and INEFFICIENCY, irresponsibility, unaccountability breeds POOR OUTCOME if you think of TREATMENT BASED MEDICINE!

2. The NEGATIVE OUTCOMES are plenteous to mention in the exercise of high quality health care because of the human spirit!!! Communism breeds oligarchy, bigotry and KILLs the human spirit to succeed!

HOP!!!! WARD DEAN is in lullaby landing this Obama days!!!

The "crisis" is not about healthcare - it is about health insurance. Physicians are being scapegoated here. Physician salaries only make up less than 10% of the healthcare expenditures in this country (allowing for skimming from the insurance companies, hospitals, office overhead and expenses)

davida788 will you help them write the bill? I see no flaws in your plan.

If we are to own this discussion, then we need to be a LOT more than just naysayers. We need a plan of action that will provide financial relief for the system. Why is the converstaion on doctor's salaries instead of gross, overbloated income of insurance companies? You have allowed the discussion to go into negative territory. To be a leader, you MUST define your objectives and not just be a whiner. What do we stand for as a group? What is our core objectives? How do these core objectives meet the URGENT NEED FOR CHANGE? How can we work with the administration to make these changes happen? How can we demonstrate this to the politicians and the public? These are urgent questions that must be answered by Sermo to make a difference. Please stop being the "no" people (like the insurance companies and a certain political party) and come up with some real answers!

If doctors are paid on salary, they will simply be not as productive and not as pushed to work as hard as you can. When you have that incentive to do more and get paid more it works. Furthermore, if the docs are salaried then everyone affiliated should be salaried as well including the nurses, NP, PA, etc. That is the exact system that is in place at the VA hospital and Indian health system and I have worked in both and found them to be very miserable excuses for adequate health care. Government run medicine seems like a very bad idea to me, it is much better with less regulators trying to manage a patient in a cookie cutter fasion.

As a salaried employee, I would expect to join a union and to be able to negotiate my salary to keep up with the cost of living. Blue Cross Blue Shield which covers 2/3 of my patients has not allowed me to increase my reimbursement rates for the last 10 years while they have increased our health insurance premiums by 420%!!! I am losing money by providing good medical care. This is not sustainable for me.

If Mr. Dean is looking for a simple answer, which it appears he is with his blanket statement, I would suggest all attorneys be placed on salaries first. If we did away with the profiteering of malpractice attorneys, instituted tort reform, and salaried all attorneys (and managed care for that matter), we would not have the skyrocketing costs of health care we have. It all comes down to fair trade. We are already bound by Pseudo-racketerring contracts from managed care and government that no other profession is bound by. We've already seen the destruction to our primary care base. Enough is enough!

welcome to United Socialist of America

In Russia people wear nice cloths , but go nowhere , only visit nextdoor neighbor, this is what Dr. Dean wants , we should follow ,

Everyone has incentive to work , once incentive has taken away by force , we should may live in russia , large country with 11 -13 ( ?) time zones , Every one has right to make a profit .Once right of making profit taken away ( Dr. Dean : you should publish your 1040 for last 2 years and list of asset you hold ) you are not talking doctor's mind and pain we are going through day and night

Roger Cyrus, Family Medicine All of the comments ignore the fact that we cannot afford the present system of healthcare. That is what the debate is about. It is not about incentives to work or who pays for medical school or what medical schools cost to attend. Two of the main drivers of escalating costs are first: how physicians are presently paid and two: how we fund the system that pays them. In all fairness to Gov. Dean, he is applying economic logic to the current system that pays physicians like factory workers and constantly drives the cost of healthcare higher. Why not salary physicians on the model of the Cleveland clinic? It makes economic sense .

If physicians are salaried, we should have a say in the salaries and be able to unionize and strike.

This proposal is trouble. To my knowledge, all prior experiments to make people equal have failed. Within any type of health care system there must be a way for people to strive; there needs to be incentive to be better. Good doctors should be allowed to rise to the top.

The medical profession is on the brink of being altered for ever. A salary is one way for a bureaucrat or manager can forecast and contain growth, expansion and expenditure. The flip side is that the medical profession as a profession and the medical science will end up going no where. Its growth potential and its ability to evolve will be governed by the whims of the bureaucrats and politicians. In the big scheme of things, this form of socialist reform will seek equality in restraint and servitude and you the individual physician will become interchangeable, and if you buck the system will become disposable.

We are organizing a march on DC October 1 to stand up for our profession and value as physicians. Please join us then. Visit www.MillionMedMarch.com
for more details.

Sure pay for medical school, increase resident salaries, pay my overhead, do away with malpractice and pay me like a CEO. Ill be glad to take it

If you put docs on salary Obama will get what he wants: no procedures. Why would you do a T&A and risk a complication and lawsuit when you can make the same money prescribing pills with negligible malpractice risk?

Where do you think these long wait times come from in the socialized countries? At least in part from the fixed salaries.

I saw this when I was in academics on a fixed salary. It's 3 pm and the anesthesia call team comes in to relieve the day shift. A surgeon wants to put a fractured hip on the schedule. The O.R. can cover it but the anesthesia call team can't. Will you stay and do that case so the surgeon and patient don't have to wait? You will not get paid extra for this. Your salary is the same whether you do this case or not.

If you do the case the surgeon and patient benefit but you do not. They can take a number.

In private practice, you're walking out the door and a surgeon makes the same request. If you stay and work late you will make some extra money. Let's go do the case.

You can not legislate human behavior.

I have been both private practice and salaried (now I'm the latter), and I can safely say that placing docs on salary reduces efficiency and throughput immensely.

I constantly have to look for surgeons to start their cases. That NEVER happened in the private practice setting, where they would be chomping at the bit to get going. Also, there is less incentive to take on the more difficult cases if there is no reward (monetary or intangible) for going the extra mile.

Government medicine has led to a kind of norm of mediocrity in medicine, which may be OK if your problem fits into a standard cubbyhole. I take care of people who fall thru the cracks of conventional practice, and need a lot of time, and cannot even do this under regular insurance, much less government. It would be criminal for me to charge my basic fees under Medicaire, which declares how much you can charge for a given code, but does not limit how much they will pay the drug companies for medications under that same visit, So, often I help patients for far less than it would cost for pharmaceutical care, but am not compensated and would be slightly over cost if they were on Medicare. Not only is this medically and financially foolish, but it makes it harder for patients who cannot function for lack of conventional help to get care from more creative physicians who spend extra time, within the system. Placing the pharmaceutical industry on salary would be the only way to keep a level playing field for the welfare of our patients in such a system. As you see how ludicrous that seems, in an information space where we appreciate genetic individuality as a factor in disease treatment, decide whether we want to allow patients to have physicians who go the extra mile to help their patients beyond standard guidelines.

In a capitalist economy in the rest of our lives and practice, we have to compete to attract good staff, get a good office, have the latest equipment, and pay others to do the tasks our patients would rather we put off to keep up with the literature and be on top of our practices and field of medicine. I'm not sure who will pay those costs if we are whittled down on a salary basis, and what kind of service physicians will be able to provide if they have to skimp on all of those expenses in a competitive environment. Howard Dean should try practicing and running an office before he speaks for physicians about how it should be done. He is too far away from it to have any real idea what is involved.

Finally, if the government is really concerned about the health of Americans, they should seek to influence some of the major public health hazards which are causing so much harm today. The high fructose corn syrup/ sugar craze industry panders to is causing type II diabetes at unprecedented levels, putting a major strain on our medical system and costs. This, like cigarettes, constitutes just a few of the many areas where health ought to be targeted by government before it meddles with medicine. The idea of allowing irresponsible industry and consumers to make a mess of their health and a salaried medical profession to pick up the pieces is ludicrous.

cause' most of them are all freakin' lawyers b4 they became politicans, turn on any TV during the daytime and it's easy to see why they pick on docs, we are easy targets, easy game for the takin', unfortuantely we have a reputation of disgareeing with each other and NOT sticking together, that is what got us to some extent into this situation, HMO are a good example, some broke from the pack and signed up thereby making the others feel obligated otherwise they would see their incomes drop, and what happened--everyone ended up signing on and allowed ourselves to be diictated to, what BS, all that training, all those sleepless nights, all that money spent on education to have a bunch of freakin' beaurocrats tellin' us when to piss and shit, they don't understand diddly, one has to go through it the HARD way to have an inkling of how most of us feel, we are not machines, we are as human as the next fella so why are they trying to dehumanize us, treating us like a commodity, Dean is the all time chief reverse alchemist, oh ya he's a moron as well, next time I'll tell u how I really feel, dh

Before we can agree on the changes to healthcare delivery, we need to decide is healthcare a "RIGHT" or a priviledge?
And what role does promoting wellness play? We treat sickness, not health. More promotion of health and wellness needs to be advocated.
KAM

I'll be salaried the day lawyers are salaried. How about nationalized legal service. No more contingency, no more percentage, porbably no more ridiculous class actions amd personal injury cases. Doesnt everyone deserve a right to representation by any lawyer he or she chooses?

J.Pellosie Orthopedics
This is coming from one who has been in both trenches and is on the tail end of his career due to age, and feel that this was brought up to get us all upset and angry. Imagine someone telling you how much you make, how to charge, time spent with patients, time off, cme's, malpractice, as well as all the medical asociation expenses. Can go on and on and won't it be nice that they will give you a stipulated salary all you have to do is see the patient. the spirit and the care just is not the same. Now, let's get down to business; who is going to make up the salary levels and what are the equivalent levels, for myself I would say they should start at the level the Senate pays its members as well as all the bennys with it. Malpractice covered, vacations, study times, than after one year in practice we can retire with full coverage just as they do for Senators. LETS STOP WASTING TIME WITH ALL THIS NONSENSE AND BAND TOGETHER LIKE WE SHOULD HAVE DONE YEARS AGO. i HAPPEN TO LOVE MEDICINE AND LOVE PEOPLE BUT WE DO HAVE TO LIVE WITH OURSELVES AND SO WE MUST, YES, WE MUST COME OUT WITH A STATEMENT THAT ALL THE BENEFITS THAT ELECTED OFFICIALS HAVE, WE SHALL HAVE. DO YOU THINK FOR ONE MINUTE THAT THEY ARE WORRYING ABOUT WHAT TO PAY EACH OF YOU, THIS HAS TO BE DONE ON A VOLUNTARY BASIS, SUCH AS THE V.A., AND THE SERVICES. NO SUCH LUCK, THEY ARE AFTER FULL CONTROL OF THE MEDICAL SYSTEM. I HAD A FEELING THAT THIS WAS THE PROVING GROUND TIME FOR OUR MEDICAL ASSOCIATIONS TO GET TOGETHER AND WITH THEIR GREAT NUMBERS
TO GO IN AN ATTACK MODE, INSTEAD OF WAITING TILL THE SMOKE RECEDES FROM THIS BOMBING. ONCE AGAIN WILL STATE AMA AND THE AOA ASWELL AS THE AAPS AND ANY OF THE OTHER GROUPS OF MEDICINE AND MEDICAL CARE BAND TOGETHER AND MAYBE YOU CAN COME UP WITH A MORE LOGICAL PLAN OR DEVELOP A WAY TO UNIONIZE OUR GROUPS SO WE COULD HAVE MORE CLOUT ON THESE BATTLE FIELDS. SORRY FOR RAMBLING BUT DON'T WANT TO SEE OUR PROFESSION CONTINUE TO BE BEATEN UP. GOD BLESS US ALL!!!.

it sounds so sad from most of the respondents that we will only work hard and help as many people as possible if we are paid for it- w/over 50 million non or underinsured americans,we see very little reimbursement anyway...but all the reform in the world will mean little w/o tort reform we will keep practicing defensive medicine untill the fear of loosing our practice is improved salaried docs like myself will work as hard as anyone else because that is what we do we will always so the right thing why are we so different in america than every other country? my mother in law had to wait 6 weeks to see an ID doc and than the zyvox cost her $6000! how long can an immoral system that is based on money for healthcare continue

PROPOSAL TO SOLVE PROBLEM:

Put the truly needy on MEDICAID>. set up cheap medicaid CLINICS and salary those of you who want to be salaried to work there!

those with assets OR salaries TEACH THEM (NY has Regents exams where you could test for this education effect !) that if they do NOT pay for Insurance which they CAN get, that they will LOOSE THEIR ASSESTS TO DOCTORS OR HOSPITALS if they do NOT plan for disasters......sort of Like having CAR insurance and HOME insurance !!

DONOT borrow from China, Saudi, Japan, wherever , to PROVIDE INSURANCE FOR THE ILLEGALS NO OTHER COUNTRY DOES>> and we should borrow on our enslaved NECKS TO PROVIDE FOR THOSE WHO COME HERE ILLEGALLY to support the Democrats! the Democrats have ALL FOUR FORMS of government medicine in DISASTER and force charges to be paid by private insurance!

PUT CONGRESS AND SENATE AND PRESIDENT ON MEDICARE and their KIDS on MEDICAID and SOLVE THEM FIRST!! and please really take care of our VETS ..!! they need sometimes Psychological Help as families under stress or returning form war zones!! why is this always a game to not help the MILITARY Families! sorry to the Indians but i think it IS TIME FOR THEM TO SUPPORT THEMSELVES.. like the rest of us! too many years of opportunity have gone by to say that We need to pamper them! forever! sorry my family did NOT PICK A FIGHT!

If the government wants to refund my medical education and pay a salary of 250K, plus all my overhead expenses, vacation time, disability, medmal insurance, and pay for my office staff as well, I would give that some consideration, but that is NEVER going to happen. We have all dedicated a HUGE portion of our lives to medical education, not to mention the cost and opportunity cost. Someone who gets their MBA is sometimes several years ahead in retirement savings compared to an MD. Morale among MD's will only get lower. The government is making a huge mistake and listening to the wrong players. And as demonstrated in the CNBC interview, Howard Dean remains an idiot.

Being salaried and having a public option are separate issues. President Obama's plan does not call for salaried physicians or a single payer system

Medicare is my BEST paying insurance company by far. They allow about $100 for a level 4 (99214) when most of the commercial insurers allow $50-60. They do not require a precert for an x-ray or MRI or for physical therapy.

Personally, I think a single payer system would be much better than what we now have. Why should we paying a large part of our health dollars to profit-making insurance companies with leaders who make $25 million dollars a year (or more)? I'll bet there is no one in the Medicare department who makes one-tenth of that.

Wouldn't you like to have fewer hassles and better pay, the way Medicare works. I am looking forward to having Medicare for my insurance in three months instead of the bad HMO I have now which requires a referral for me to take a deep breath, as I am fond of saying.

we ned to rally....the med march would be a great show of force...enough is enough..as someone posted here, we could walk with an empty coffin--signifying the death of "your doctor's practice".....if this goes thru this is nothing more than COMMUNISM, forced slavery...

we could also then say THE GOVERNMENT needs to regulate lawyers,wall street, plumbers,etc. pay as well...I still cant believe so mnay docs are so IGNORANT...we have to organize and take back our profession!

Can we try to make the lawyers work for a salary too !! Physicians are not going to work for a salary. If it is forced upon us, they will have to turn to the mid levels !!

andyw77 Rheumatology - I agree.

As a Canadian citizen practicing medicine in the United StatesI think I have a unique perspective on this situation oops I mean disaster that The President and Howard Dean are pushing. Salaried physicians have NO incentive to work. waiting lists develope for surgeries. Patients wait weeks to see a PCP and months to see a sub specialist.
Mr President Take a look at the Insurance industry in this country. Make them liable for their decisions. Look at the billions of dollars they have in reserve in the banks an interesting concept for non profit companies. Pass tort reform your lawyer friends have convinced the public that bad outcomes is the same as malpractice I can assure you it's not!!
To all my physician colleagues NEVER let the government run health care if we must withold services to get the publics attention so be it .We are not blame for the state of healthcare today and i'll be damned if the government makes us their scapegoat!!!!

that's bureaucrats and not beaurocrats, sorry I'm not Indian, dh

Just talked to a neurology colleague in England who admitted outright the ONLY reason doctors in the UK stay in the NHS is because of their pension. as was pointed out above they have no school loans don't have to fund their own retirement plans as well as provide for their family and at age 60 got 60% of their salary for life and the surviving spouse gets it until their death! They get extra added to the 60% if they do special research, teach at a med school etc. THEN at age 60 they start to work 3 days per week at 40% of their salary so as long as they do that they continue to make 100%. Now here's the kicker...he admits the system as they have it now will collapse within 10-15 years maybe sooner. Already their banking institutions have changed their pension structures. Guys, it is a house of cards. Let me worry about me. Churchill said when you give up your autonomy for security YOU LOSE BOTH!!!

THOSE WHO SAY MEDICINE IS A CALLING are not those straddled with EXCESSIVE MEDICAL SCHOOL DEBT!!
YOU DO NOT go into DEBT to go to the MISSION FIELD!

we have a problem , as physicians , here at sermo.. each should be required to disclose how much med school debt they had!! truth is that NOW any student who had working parents with median income are NOW DEBT SLAVED..

the AMA makes a game of the TRUE AMOUNT OF DEBT.. they AVERAGE ONLY MEDICAL SCHOOL amounts of those withe real DEBT with those who have NOT DEBT!! If you have no debt, it is easy to go to work on salary.. and remember YOUR SALARY WILL BE REDUCED WHEN ALL ARE ON SALARY ......!!Donot think anyone thinks YOu deserve anything for your 24/7 work! SELFISHNESS reigns more that professional respect esp as long as no Legal Reform addresses the NEVER A JURY OF YOUR PEERS but a game of deception and lawyer/ judge Greed

Sure I'll take a salary. I'll also stop getting up at 3 a.m to deliver babies and I won't take phone calls after 5 pm anymore. I'll not work my ass off in the office to see so many patients (which means instead of a 4-6 wk wait, they will wait 3-4 months to be seen) and any patient with the slightest risk or complication I'll send elsewhere.

In short, what the hell will I care anymore, I'm a lazy salaried employee of the federal government, just like the rest of them.

Most of us have spent time at a VA hospital. I love our Vets, 97% are the best people in the world. But it is not a system which resembles anything other than "molasses in January." Honest people know it only functions well when linked to a hardworking young group of docs in training. No cases start in the OR unless they can be finished before shift end (that's 12, noon if you want to even think about a start). We routinely ran out of LR at the Hines's VA in Obama's old home town, Chicago (Maywood).

Gov. Howard Dean is totally, I mean totally, clueless. He is so far out from having to run a medical office he should consider surrendering his medical degree (yes, I know that's silly, but I think you get the point). He betrays his medical colleagues who actually have to raise a family, run an office, and not run around paid for by the Democratic Party attending news conferences, fundraisers, and give out inane opinions on CNBC.

The are a large number of physicians willing and able to provide cash medical services just across the border from Dean's nirvana, Canada, in Bellingham, Washington. Obama, dean, Pelosi will never have to suffer the fallout from the crazy ideas they are pushing in DC. Kennedy flew on a private jet down to Duke University to receive his neurosurgery, then his relative promptly declared "I can't wait until we can provide such fantastic care to all Americans through a government run healthcare system." Give me a break, you or I won't get that level of care in a government run system.

These promoters are totally clueless, disingenuous, or outright deceivers.

"We're all doomed!" -- Private Fraser

Salaried and at fixed hours would be fine with me, but that is going to cost more than they are already paying!

What works in Europe (some of the socialized systems work well but are expensive$$$) is

Strong physician union
Hourly pay
Overtime pay
On call pay
Strikes!
Option to work outside of government job part time (private consulting)

People still unhappy about physician availablity and MDs can work outside the system.

Dr. Dean is smoking something if he thinks this will make health care cheaper or better.

The VA is the scariest vision of what this type of health care system is about.

Gbowen THANKS

i have tried to tell the little guys here in ny who always say how great it is in Canada that the biggest DIFFERENCE is that , in Canada YOU are allowed to FINISH the INFARCTION and end up with damaged Myocardium that leads to terminal CHF.

HERE THE creativity and PRIVATE MONEY went into Developing procedures that get perfusion back and SAVE MYOCARDIUM..!!

it is NOT just CANADA,, it is EVERYWHERE IN THE WORLD where socialized med exists.... YOU LOSE CHOICES TO GET better as it becomes very hard for you to find a doc who will LET YOU PAY CASH to get the better care....esp if they are on your insurance plan they are stuck with contract law..

We associate being salaried with loss of control. Unfortunately, It can't be that bad. Most professional athletes are salaried. They don't have big office overheads and exhorbitant malpractice premiums, and when injured they still get paid a bonus. So there are benefits here as long as we have good attorneys to workout the contracts to include malpractice lawsuits against uncle sam.. All said and done I have not heard anybody mention "tort reform" as if its not part of healthcare reform. In the final analysis if all physicians are salaried, maybe we may not have to look behind our backs so much about being sued. And perhaps our patients will all be appreciative of the best efforts we put to maintain their good health and livelihood.

As a salaried physician, I can assure Dr. Dean that this facile "solution" doesn't fix the problem. Invariably there is a practice CEO or Dean who is paid handsomely to make the practice profitable. He/she urges (sometimes with a carrot and sometimes with a stick) the salaried docs to generate more income. Guess what? the salaried physicians are back in the old fee-for-service paradigm. It's amusing to see the policymakers channeling Abraham Flexner's century -old fulltime salaried physician scheme as a panacea. Osler saw its flaws and so should we!

Depends what the salary is, and I also assume like in Britain (where I was a NHS doctor until 12 years ago) the government also pays all your overhead, medical education, liability costs, pensions and we could unionize and bargain collectively. If it is just a salary and rest of the current system stays then practice isn't financially viable and most private practice doctors would quit - but perhaps that's what they want.
I would let collegaues know that when you are on a straight salary there is little incentive to work longer, see that extra patient, go further to meet what are sometimes unecessary demands but what patients want. The patients have to take it or leave it and the doctor doens't have to worry about losing customers and income.

We need to attack Dean's drivel with satire. Reason does not work in the current "twilight." I refer anyone interested to my webite, www.localhealthcarereform.com, where the "De-spamanator" tab features recent satires proposing a single payer system and cap and trade approach to addess nutrition contributing to poor health status.

It is all the same ideological garbage that the "free market" does not work and any person or entity granted economic freedom will use their individual autonomy and initiative to exploit mankind, not contribute to its betterment. So government has to control all means of production of goods and services to assure this does not occur. Of course, there is no mention of the innovation, productivity and progress that also results and could be lost..

Of course,everyone should be on salary determined by the government to avoid such exploitation. As I wrote in one of my satires, we all know the free market does not work in the food indutry. Grocers and restaurant owners are beseiged by giant food corporations who - in exchange for free samples, pens and vacation seminars - entice them to force consumers to over-consume expensive "brand name", processed, packaged and fast foods. Otherwise , consumers would purchase, prepare and consume at home healthy, locally produced, low-cost, much more nutritious, generic food items leading to improved nutrition. Nutrition and health status would greatly improve and food costs plummet. Therefore, to combat obesity and other health conditions, and reduce the high cost of nutrition, all restaurant owners, chefs, and grocers should be salaried.

Jim Felsen
Charleston, WV

I personally voted positively on the questionnaire side-bar (i.e. favorably for "salaried MDs")--not with the naive enthusiasm of the US liberal-left but with gritted teeth of a soldier, like the S.Vietnamese April 30, 1975 or Germany 1919 at Treaty of Versailles, i.e. enjoy your war, the peace will be much worse!

As I've already indicated in several previous Sermo columns, the fustian penumbra of socialized medicine will require the sinews of Stalinism in order for such a system to function, viz. indefatigably ruthless rationing of consumer demand & provider supply (e.g. nat'l identity cards, age limits for various types of advanced care, tightly capped fees, wages & benefits, mandate of providers by speciality & region) . Nonetheless such ironclad socialism brings benefits intrinsic to it, e.g.:
>Abolition of the present lawyers' bonanza-sweepstakes of medical tort;
>More intensive use of GPs 9instead of specialists);
>Low out-of-pocket fees for pts & their families;
>Equity labor conditions [more MDs mandated to some nite call, ER &/or administrative 'paperwork' medicine];
>Many MDs will have lower incomes but also will have shallower pockets for mercenary attorneys [as well as lower target profiles for jealous non-MD allied health care professionals];
>Docile health-worker trade unions.

To come back to original historical analogy:
>The S. Vietnamese suffered 1975-circa late 1980s when the Communists decided upon doi moi [free market] economic reforms.
>Germany eventually got on track, circa 1990s, fall of Berlin Wall & collapse of USSR.
>US socialized medicine would eventually have to re-introduce some free market traits.

Thanks for reading.

The issue discussed here is definitely multi-fasceted...

If the USA is to continue to be a capitalist nation, then doctors, just like any other professionals, need to have choices. If one prefers to have a private practice or be a part of a private practice - they need to have that option available to them.

On a more global scale, it is becoming more an more difficult to have a small business - not just in medicine - because of the changes in the economy in general.

I think that countries like Israel, for example, have a fairly good system - there are two types of doctor practices - government sponsored, and private. The government sponsored docs get a salary, don't have overhead, and probalby overall make less money, but don't have to work as hard. The private doctors charge cash, meaning there's no insurance involved. For any doctors, education is virtually free (definitely not as expensive as it is in the US!), so that problem is not an issue at all.

Anyone who suggests that one solution will fit every individual within the field of medicine is not very bright. We need to continue to have choices - both patients and doctors.

I would invite Mr. Dean to go and sit in a busy ER, or even the DMV and see how long he has to wait for service. There wouldn't be much difference in access to health care if the government took over. Why do they think this would work?

?

Many do not understand the implications of being salaried.

Productivity and procedural standards are put in place. Compensation is set by the employer. The doc dosen't have the choice of how many patients are seen, how much she/he works and what medical guidelines are to be followed. Those are all dictated to the doc by management. Liability coverage is provided, and the doc dosen't have to worry about the billing or overhead.

There are pluses and minuses.

It is a "Take it or leave it" situation

Independency is lost. Some docs want this; some don't. It is an individual thing.

Only salaries? No way. I am sorry, but this would be unconstitutional. The choice should be up to the individual practitioner, not the government or any other entity enforcing this on professionals, presumably living in a free country.

If they want to pay me a salary, they can pay all the expenses that go along with this type of work- malpractice premiums, cost of employees, liability insurance, medical supplies, office supplies, utilities, etc. I will work on a time clock and when the time is done, they can find someone else to take care of the patients for the next shift. It can be like a factory. This is what will happen anyway. It is happening with hospitalist programs already.

I would take a salary, how about the same as an average baseball or basketball player, maybe an actor's salary would be nice as well.

Very important point--IF YOU ARE SALARIED, YOU CAN BE FIRED! I see colleagues of mine who sold their practices after 25 yrs and worked a few years for the System, then got canned. Now what??!!
Privatization=incentive, striving for quality, keeping overhead in proportion.
Decide: employer or employee-that is the critical mass
PS Lawyers should be salaried as there incentive is to drag out issues to make more money. A divorce is woth $5K-take care of it in a week or 2 years-your choice

Former Governer Dean is really showing that his heart lies in politics and not in medicine or for that matter the patients that those in medicine takes care of. Going to medical school is only the first stepping stone to calling yourself a doctor. Residents are on salary and are limited in the hours that they work. Put physicians on salary and we too will be limited (self limited?) to the hours we work. Remember we have families too, and would love to spend more time with them. Put us on salary and watch how the work week shrinks.
Does he also agree with malpractice reform? Goverment paying for medical school?
It is time for physicians to gather, leave the AMA (hard to believe that 20 percent still belong) and form a stronger, physician oriented group. I am ecstatic to have found Sermo. INVITE ALL YOUR PHYSICIAN FRIENDS TO JOIN THIS GROUP, PUMP UP THE NUMBERS AND LET'S PUT THE AMA OUT OF BUSINESS!

The solution is to cut people off! People need to change their attitudes about healthcare. Just because you can go to the ER for a cough, doesn't mean you should! Cut the legs out from under these money hungry lawyers and get tort reform nationally. We practice defensive medicine, which is not good care. No one hesitates to order a $1000 test if they feel it will cover their behind. Stop wasting resources and healthcare cost will go down!

Here's a question for all you pro-salary fools who think that we should all fashion healthcare after the likes of Mayo and the Cleveland Clinc

*****GUESS WHAT*****

there is healthcare being delivered outside of the major metro areas! Can you believe it?!?!?! YOU MEAN OUT IN THE COUNTRY?!?!?! I work in a rural family med practice. What's going to happen to patient access when I go from seeing 35-40pts a day down to 20 because that's all I have to do, and there is no incentive to do more. Multiply that by the other 4 docs in my clinic. I can't believe the idiocy of some of these comments....luckily they seem to be in the minority here on Sermo at least.

The additional disincentive for a salaried MD is that liability does not go away. Why see more patients if you're income doesn't change and if you incur more risk? The natural reponse would be to see the minimum number of patients and to avoid nights, weekends, etc. A Massachusetts commission is going to recommend statewide capitation. In that environment, if you are salaried, the patient becomes your advesary.
What would possess anyone to think Howard Dean has anything worthwhile to offer - a failed MD, a failed candidate, a failed party head.

Physicians on salary, what a great idea! The mind boggles at the prospect of other possibilities. I wonder if lawyers should be on salary from some governmental payment system as well. Think of the price reductions to consumers of legal care, AKA clients, that could be brought on by that. Other professions, such as accountants, should also be considered to be on a salary determined by a close relative of Big Brother.

Do you think I could pay my student loans back in rupees?

Doctors seem to have the attitude of complaining to each other about how bad things are, but no one seems to be standing up to people like Dean! We need to put some serious money behind this cause and get some lobbyists on our side!!!

Yes indeed; a great forum here.
A Choir, perhaps.
Too bad it is without an audience, (aside from ourselves.)

howard dean hasn't practiced medicine for years if at all and should not be allowed to speak as an m.d. representative. salaties will ruin health care as we know it as many have said. we need reform, but only of the insurance system, ie cross state lines, limits on nonmedical expenditures, eliminating all preexisting clauses, and a catastrophic ins pdct and pooling for uninsured to reduce costs and complete portabililty.

Howard Dean is an idiot. Anyone used to working for themselves will not be motivated to do one extra ounce of work with a system like that. I see a physician revolt coming.

Howard Dean thinks the entrepreneurial model is at the root of the physician cost problem in healthcare. HE IS CLUELESS.

There is a reason why the practice models that exist at Mayo, Kaiser, and the Cleveland Clinic are not the dominant models for organizing and compensating physicians. The success of these systems is heavily rooted in things other than the way they pay their physicians. You cannot extract one aspect of a successful system into a different system and expect the same results.

During the 1990s there were a number of health systems that bought-out physician practices and put the physicians on salary. The results were largely disastrous for the finances of the systems because without a profit motive, physician productivity fell. The lesson from this is that nothing keeps up productivity better than having a profit motive.

We have a shortage of doctors already. What's going to happen when they cut back hours because they're not getting rewarded for extra work? Before you say mid-level providers remember that PAs and NPs do not do surgery, major invasive procedures, or any number of a host of subspecialty services.

This proposal is the product of government policy wonks who don't understand enough about the system to see how their proposals don't work.

I have worked on both straight salary (in the military and an HMO) and on productivity. If you pay docs a salary regardless of work done, the following happens, cause docs are smart people.
1)The first thing I want to know is how little work I will have to do to get that salary. After all, why should I work 10 hours and see 30 patients when i can make the same for 6 hours and 20 patients. And why should I add on an "extra" patient to a full day?
2)I will start telling my sickest patients that they are "too complicated" for me and need to see a specialist. Again, why spend 20-30 minutes with a sicker patient when you can see a healtheir one in 10-15?
3)I will not take any after hours call or weekend/holiday work without being paid extra.
4)I would probably advocate a doc's co-op or union to negotiate with the payers, as an individual I have too little clout.
5)I will retire whenever I decide it's not worth it any longer.
Multiply this by the number of docs over age 55 and you can see why salaried docs = instant shortages and longer waiting times.

When President Obama states that Physicians would chose to take tonsils out of our children for profit, and Howard Dean states we should all be salaried- we ALL NEED TO BE VERY CONCERNED.

The simple concept that our president introduced in a prime time news speech - namely that doctors put profit in front of patient care (especially children's health) is very, very, very disturbing. We ALL NEED to be up in arms, or will be vilified to promote a political agenda that will deeply harm our country. We must all be vocal- through our Washington representation, through the media and we must discuss this danger to our patients- let them know the disaster that awaits them (us) all !! The powers that be in Washington are now openly hostile to the medical community.

The only way this would ever be implemented is if it becomes ILLEGAL to be an independent contractor. This would lead to physician strikes, with predictable results.

How about FREE dental care for EVERYONE? How about FREE veterinary care for ALL ANIMALS? After all, aren't Spot and Fifi "almost human"? Why should those "greedy dentists" and "expensive vets" get off Scot-free? What about free electricity and free utilities for everyone? Health care reform has not passed and will not pass unless Congress can figure out a way to avoid having to participate in the Ponzi scheme they propose. Invest in funeral parlors because they are going to do a bang-up business under Obama-care. I say impeach them all and start over. What is good for the goose is good for the gander. Howard Dean is an idiot who long ago gave up what mediocre skills he may have learned to become a politician. He is a disgrace to my profession as he puts politics over his and my patients. My father always told me, "If it isn't broke, don't fix it. It may only need a tune-up." Yes, medicine has problems but the "greedy doctors" are not the sole problem. How about allowing physicians and other health care providers to deduct the cost of services they perform but for which they are not paid? Attorneys can. How about tort reform so that a physician does not risk everything they own to take care of very ill patients with difficult problems and still not GET PAID? None of the current "proposals" that I HAVE READ (unlike the members of Congress who get PAID to read them) address these problems. Until they do, LEAVE MY PATIENTS ALONE and let me take good care of them without the government in the exam room or the operating room. Under the current proposed legislation, both Teddy Kennedy and Arlen Specter would be dead...but, I forget that they are "better" and are, therefore, exempt from any laws they pass. Like everything they touch, the government kills inventiveness, personal achievement and legislates mediocrity.

Too many of these postings are too apocalyptic, they generate much more heat than light.. .. I have been salaried and done private practice.. .and I can assure you there are pros and cons to both. I currently do both, salaried Mon to Fri and work private on saturday for fee for service in a friend's private clinic. The point is that salary with productivity incentives can work quite nicely. If we were spared malpractice and office management hassles, who could complain about that?

There must be a choice... MD's should be able to work in a private or government group on salary with productivity benefits, or should be able to be solely in private practice... Each doc can choose what is best for themselves...

No problem..

What should NOT happen is a government edict that this is what we must do, etc...
If Dean meant that ALL docs should be salaried, then he lacks understanding of the realities of medicine in this country. If he meant that most could be salaried, if they wanted to exchange a lower income for more humane hours etc... that is fine. It should remain an individual CHOICE.

Comrade Howard Dean essentially is trying to create a socialistic society. Maybe we will be like the docs in Cuba. We can also drive taxis for extra bucks. It's fascinating how rapidly our society is changing.

Howard Dean is a socialist moron. What an absurd statement. I have a better idea. We go the other way and all stop taking insurance (fee for service only).

His proposal is pure socialism!!! Why doesn't he want to put all lawyers on salary?!?! Consider that cost savings!

Furthermore, who would salary us? How does one compensate for years of schooling, thousands of hours studying, hundred of thousands of dollars in cost of schooling, stress, and 100+ hours a week away from family and friends during residency? I for one would change careers.

When you decide to salary MD's, you should then also salary every lawyer, architect...in fact every professional. Then we become a socialist country!

And by the way, when you do, no longer will the top 1% of college graduates, from the top 1% of high school graduates become doctors....enjoy have your family treated by an MD from Guatemala!

Perhaps Dean should consider the above factors before spewing idiocracies!

There are successful models of salaried physicians, with the Danish people happiest in the world with their health care.
NOTE: every socialized system has some opt-out mechanism for those who choose more rapid access to care, with the U.S. providing much of this high-tech opt-out. If ours goes away, there will be a ripple effect to the now-happy socilaized systems, with overall decrease in the boutique end of health care.
But money can buy any care, but not necessarily better care or better outcomes, as the late Michael Jackson proved.

Who cares what Howard Dean says. This type of question is ENTIRELY off the mark and is yet another example of the powers that be controlling the agenda by introducing secondary points.

The debate was farsical, again because third parties set the agenda - malpractice reform??? WTF. The whole thing made concerned physicians look like a bunch of grasping whingers.

Steve (the 'economist') and Erin (the 'new' Maria) are a joke and a bad one at that. Whom do you think they are speaking for? Patients? Concerned physicians? The medical green machine? I'll opt for the third one.

Until and unless physicians suceed in having the excesses of the machine pointed out and remedied, reform isn't going anywhere.

Ask yourselves. Who's paying the nickel for the 'blue dog' Dems. Patients? Concerned physicians? Le machine? Again I'll opt for the third one.

Round 1 to the opposition but the war isn't over by a long shot.

Nothing says productivity like a guaranteed salary...

to: drness1

Tort reform will not occur in Obama's watch. The reason is our secretary of health is non other than Kathleen Sebelius who is the biggest lobbiest for the trial lawyers group. The AMA was blindsided by a carrot and now we will get hit with a sledgehammer.
Ambulance chasers rule our society.

I do not wish to put any physician down. That said, consider how patient care generally was (i.e., not in all cases) when you worked for the VAH or when you were in the military, or worked at a charity hospital during training. It will be different for everyone, but is a basis for comparison taken from personal experience.

I have been salaried hospital employee since residency. It worked for me, with M-F 9-5 work days, little or no call, medmal, health coverage and 403B are good. Don't care if a pateint has insurance A, B or none at all. Could moonlight on nights/weekends but so far did not feel the need to. Of course, there is a downside in a sense that I have many bosses, paperwork, rules, regs and more paperwork. Got sick of it, so decided to switch to psych ER. Still salaried, same perks but even better hours (3 12-hour shifts a week) and computerized.

However, just because it works for me does not mean it should be forced on anyone else! I guess one reason it works for me is that in psychiatry there are no procedures besides ECT (which I don't do) so everything we do is office visits.

And yes, it is very true that on a fixed salary, there is no incentive to do more. I do my job and do it well, but that is it.

Don't you think the gov't will be eventually be telling doctors how many patients they have to see each day?

As a psychiatrist I can just imagine being ordered to see patients for 15 min "med checks" all day as many of my salaried colleagues have been, or face being fired.

Howard Dean was an unfortunate and misleading choice of "doctor" to interview.

Let's see: Salaried trial lawyers: Perhaps $200/hr. That seems a bit steep to me.

As soon as all lawyers go on salary, I am sure that the doctors would be happy to do so as well.....

This is a great thread and I am hopeful that some of the keen insight and observations will be used in the actual debate and development of healthcare reform.

Salute: one of my sons as a therapist was treated just that way: 15 min per pt,, complete all the mass of paperwork on his own time, etc. He left after one year.

Oh, as an aside... please stop calling docs who are salaried or who see the benefits of being salaried as fools, lazy, etc... Aside from being inaccurate, there are many quite bright and hard working doctors who choose a more sane lifestyle with less stress than that in private practice. Just because some doc on this site has a different opinion than you do, does not make them less intelligent or less hard working. We all have different life situations and what works for you, may not work for me. Salary is a sane option for many, less patients, less stress, more time with family and for avocations.. etcc and yes, less money. Each doc should evaluate the pros and cons of a situation, and choose what is best for themselves... I do not know how many docs are salaried vs private in the US, but I can see that the salaried ones are certainly not very well represented on this site...

Thank God that Howard Dean never became President.

Incentives are the drivers of productivity. If my salary stays the same (or minimally changes regardless how many patients I see) - there is no way that I will overstress myself, work on weekends, holidays. I will take every single vacation and personal day possible and overall "enjoy" my life. Unfortunately, my income will plumet to "crap" level.

agree with all the above comments they make so much sense makes you wonder why physicians have not been solicited for any opinions makes me believe that WE are considered the problem by the government

This would be nice in the short run. I'd be able to cut back my hours, see fewer patients, spend more time with my family, and get my MBA in my new free time.

In the long run, it will make access horrible when I'm older and need to see a physician myself.

davida788- great post!! you summed up very succinctly my thoughts on this better than I could! Would you mind if I cut/pasted and edited it a bit and used it for the letters I plan to write to my Congressmen??

With regards to salaried physicians- I am quasi-salaried (get an hourly base + commission). There is no way that placing doctors on salary with lessen the work load. The company for whom I work constantly harrasses the "providers" to "be more efficient". I get critiqued on how many patients I see per hour, how long it took to order labs, how quickly the rooms were turned over- JUST LIKE A WAITRESS!! So, unless that salary is pretty damn high- no thank you. I have sold my soul for a guaranteed minimum paycheck and it sucks. I can not imagine the government giving me more autonomy than corporate america (i.e. my current for profit employer).

I was a 'Psych. Hospitalist' for ~4yrs. I was treated like 'crap' & basicaly 'fired' for speaking my mind to the CEO & CFO. That was the least satisfying work I've ever done. If I had to return to that sort of job, I don't think I would continue to practice. I have been so much happier in private practice (making less money) that I can't even contemplate returning to a 'salaried' position where I would have a burocrat for a boss & be 'graded' solely on how much money I made or saved them... I once thought Howard Dean was a 'good Democrat', but boy was I wrong about him... If some Major Reform is rapidly pushed through & forced down our throat, the negative ramifications will be unbelievable & irreversible...

Just noted how this post began: "Former Governor Howard Dean" , not "Former Doctor Howard Dean." How appropriate.

The oath of Hippocrates is the first written evidence a business contract. I suggest all who haven't done so recently re-read it. This debate will quickly devolve into the question as "Which Physician's should be salaried ?. Our right to do business as both historical and protected by at present by our U.S.constitution. To force all physicians to be salaried would require a Contitutional ammendment and then of course the issue of unlawful searches and seizures,slavery,writ of habeas corpus etc. might surface.
I hope we get the picture.
Tim Baldwin MD, Oklahoma City, OK.

I am a retired physician and a VA patient with 2 happy years practicing as a military pediatrician follwed by 30 years of treating indigent mentally ill in private practice with a Monday through Friday drop in clinic plus visits to nursing homes and skilled nursing facilities. I worked long hours, but never to get paid more. I was fortunate to have scholarships and financial assistance from parents so that I didn't have educational loans to repay. Moreover,after discharge, I had the GI bill to fund my second residency in General Psychiatry.

Tort reform in the form of caps on pain and suffering substantially reduces the cost of professional liability insurance premiums in States that have such caps, e.g. California. Physicians working for the military, VA, county clinics, and many locum tenens jobs include malpractice coverage paid by the employer.

I recall being interviewed for staff membership by a small private hospital CEO , age 26. He was pondering whether to remain independent or to merge with another hospital. He said, "If we merge, I can buy 4 physicians for the cost of one Hospital Administrator." I then understood what the media mean by physicians as comodities.

With budget cuts in CA, not only are Medicaid reimbursements frozen for the past 30 years, so that a given CPT code pays less than half the Medicare rate. Moreover, services of psychiatrists in private practice have been eliminated, first by eliminating the codes for reimbursement, forcing psychiatric patients to go to county clinics. Many counties are too small to have IT departments to process billing for reimbursement, but each county now has its own newly enlarged bureaucracy with more expensive buildings, and limits on allowable visits after the first few that have to be justified by Administration with detailed and time consuming progress reports. Of course, county doctors have no overhead to pay for billing and other expenses as private doctors do.

As a psychiatrist in private practice, I was not constrained by formularies as the county doctors were. They were not allowed to provide samples of new medications, e.g. Abilify (aripiprazole), so when some of my patients sought treatment at a county clinic, they could not get that drug and had to substitute other drugs that had more undesirable side effects e.g. weight gain and higher chance of developing diabetes. The county psychiatrists were helpless and had to inform angry patients that they couldn't continue the same medication. My patients often fell through the cracks in the county program and went to jail or hospital when they ran out of medication or needed dosage adjustments between appointments every 3 months.

Fortunately, a private group with county contracts to manage the long term hospital and provide case management for the "frequent flyers" who had a history of multiple hospital admissions, started a new service like mine, only with 24 hour 7 day a week drop in service instead of just 5 days a week of afternoon and evening drop in service that I offered in solo private practice. A nurse is on duty at all times and psychiatrists work a few hours each day on week days. Patients are limited to a single visit but can sometimes get a refill or two while waiting the 3 months to see a county psychiatrist. However, social service workers are the gate keepers , screen and diagnose by telephone after long waits, and deny appointments to psychotic patients who acknowledge drinking in the past 6 months. Impulsive patients with inadequately treated Bipolar Disorder are sometimes misdiagnosed as having Antisocial Personality Disorder and denied services until they try to hang themselves in jail. The county doctors are probably mostly unaware of the suffering of psychotic indigent patients in the community who are screened out.

I will accept a salary if I have none of the BS paperwork, pay all the expenses for my office and they take care of he employees payroll, Health insurane and all the Dean mandated benefits for me , my employees and their families. Dean was running off his mouth and not really thinking that day. He was sweating so profusely I thought he would pass out, particularly when Dan flashed all the flagged pages of Dean's Magnum opus!

ajaymd has the right answer. If the salary is high enough and the work load low enough, there won't be a problem. The questions in the survery appeared to be particularly poorly designed to get meaningful answers.

The primary goal of Obama's agenda is to drastically reduce Physician compensation while doing nothing to reduce practice costs. In direct contrast to what he said during his talk at AMA, most of the "savings" in his health care "reform" package WILL ABSOLUTELY come off of the backs of Physicians. Despite this, like lambs to the slaughter, most physicians stand idly by as the last remnants of their profession, as well as US health care in general, is destroyed by far left socialists like Dean.

Will you be on salary in Saudi Arabia?

I am salaried and note that the only way to survive is to set limits, and if you cannot or will not due to sense of altruism, work ethic or duty, the system will eat you up and you get burned out. The salaried system does not have any interest in protecting you, and in fact wants you to work harder for a set compensation.

If the predictions for less physicians is a true one, the future is very dim. What bright young college student is going to want to endure another 7-10 years of postgraduate training to come out and work for a government set salary while his or her peers are in the workforce a decade sooner in positive cash flow and not accumulating debt.

In order to save the future training of doctors if a government salary is the future, the only way to get smart people to actually want to become a doctor is to make medical tuition free or subsidized by the government and admissions very competitive, and then have any school debt as a tax right off like a mortgage. Otherwise, what sound minded individual would ever entertain medicine as a career?!

I also posted this on the "CNBC Debate To Feature Sermo Physicians, Monday 7/27/09" posting, but it seems more appropriate for the focused group here...

Daniel said towards the end of the CNBC Howard Dean debate, "Physicians need to pe paid in a way that's commensurate with their training and skills."

I wholeheartedly agree, Daniel!

I've seen the shift-work mentality of salaried anesthesiologists at some hospitals (both academic and private) but specifically chose not to join such a practice. An anesthesiologist's work day (and the amount of compensation earned) varies widely according to number of cases, severity of patients' illnesses, type of procedure, type of patient monitoring and plan for postoperative pain. Patients are treated individually according to their specific needs as the anesthesiology care provider devotes his or her attention entirely to the patient being cared for. Generally speaking, the more we work and the more patients we care for, the more we get paid. Productivity-based compensation helps ensure rapid OR turnover and improved OR utilization without increasing unnecessary anesthesia procedures, as the anesthetic plan is tailored specifically to each patient's needs. I worry that productivity may actually decline (amongst surgeons, anesthesiologists, cardiologists, gastroenterologists, and innumberable other specialties) if we all become salaried employees.

Physicians have traditionally been the weakest political link in the chain, and therefore the easiest target to bash.

I have not heard much about curbing the millions of dollars paid for end-of-year bonus to CEOs of insurance companies.

In order to assess where health dollars are presently going it is useful to compare the discrepancy between a physicians office and the penthouse floor of a liability legal firms.

I do agree with being a hospital -employed surgeon.
I still feel free to manage my patients, many of whom do not have insurance. I do not worry about reimbursement, or even bother to look at the patients' "facesheet" to see what type of insurance they have.
Access to healthcare? Many of the private surgeons say they cannot see certain patients in their office because they have only medicaid; so they send them to me.
Many of them, I think do unnecessary procedures, and order unnecessay consults to other private docs.. (I'm guessing it's because someone wants new shoes,.)
I feel I do what is right for the patents because they are my only concern, money does not even enter into the picture.
I drive one of the nicest cars in the doctors' parking lot, and live in a nice house. Despite a big student loan debt, I am finacially comfortable.

Everyone knows lawyers are greedy, and soon the general public will speak that way of doctors if you keep complaining about money, instead of the real issue.

I don't mind being on a salary. I am already working for the government. However, doctors salaries are not the problem with healthcare. The problem is that it has become a for profit industry controlled by those who would make a profit from the illness of their fellow citizens. They have no direct connection with the patient, neither do they care as long as they can make a profit. Doctors are directly in contact and caring for the patients, and I would venture that 99% of us are directly concerned about the health of each individual patient, and doing our best to care for them. Salaried or not would make no difference.
We need to get big business - HMO's, the Blues, HCA etc. OUT of the medical equation.
If having the whole system socialized under the Feds would do this I would be in favour. However, I see as much if not more corruption within the Federal system I work in. It is a constant battle to have my patients receive the care they deserve.

There should be 2 disease tracks covered by insurance:
1) Chronic disease ( cancer, diabetes, metabolic syndrome, hypertension, developmental issues, etc) that should be covered by the Feds. Care should MOSTLY be given by specifically trained NP's & PA's, supervised by a doctor who would see the patient once or twice a year in addition to 4-6 visits with the midlevel. Ther would be algorithms for care, and Centers of Excellence located in strategic areas across the country to refer complicated patients with thses conditions. Care for chronic conditions would be provided in VA-type clinics, and all providers would be salaried. Tracking software would help ensure compliance with the algorithms and would track outcomes, giving data for analysis and updating of the treatment protocols annually.
this would mean that all subspecialists caring for chronic disease would be UNIONIZED government employess with the right to strike.

the Gov should also pay for well child care & immunizations through age 5, but the arrangement with FP's or Pedi's may be different

2) Indemnity insurance would cover only "get hit by a truck" conditions, such as major trauma or hospital bills > $5k. They would need to lower their premiums accordingly. They would have standard NATIONAL rates, and would need to offer the same rates to ALL businesses to cover thei employees.

3) For all other medical expenses, you're on your own, but you should be able to put $5k pretax away for a medical expense account that could be rolled over to the next year, with the balance invested in something safe with a 4% or so intrest rate.

grampyjoe writes:

"ajaymd has the right answer. If the salary is high enough and the work load low enough, there won't be a problem. The questions in the survery appeared to be particularly poorly designed to get meaningful answers. "

And if the fairy princess drops off a winning lotto ticket I can work for the govt for free....

One only need look at the salaries of Docs in any Single Payer system to get an idea of what a Doc's salary would be in Dean's utopia. How can anyone seriously consider that Doc's salaries under Dean's system would be "high enough" or the work load low enough??? Just look at the poll and or use common sense: Such as plan would drive Docs by the hoards out of medicine. There would be far less Docs to treat an ageing and growing population. Less work? Of course, NPs, CRNAs, etc. would replace Docs. Great for pt care.

Why do you think that 13% of Canadian Docs come here? Imagine how many of the Brit docs would if it were more practical.

If we're salaried and work for government, they should pay our medical education AND our malpractice insurace--just as currently I am on faculty at one of the top 5 children's hospitals in the country on SALARY (gasp!), and they pay my med mal insurance. In fact, I have no clue what my med mal insurance costs, nor do I care. Nothing wrong with salary. I work just as hard to be efficient, improve access to care for patients, and teach med students, residents, and fellows, as I would if I were not salaried and ate what I killed. I see no problem with salary. This ridiculous survey to the right completely ignored academic salaried medicine as an option!! Thank God there was an "other" option to add it. Another biased, stupid survey from DP.

I really don't understand these voting questions... What does "Federal Involvement" mean? Too vague... These questions are biased and therefore will not provide accurate results.

"Freedom in America is under assault, and has been for a while. Leviathan happens during wars, economic depressions and natural disasters--that's where you get government growth. The fact is, governments take advantage of crises to amass more money and power.

The good news is the freedom movement is back in gear. The bad news is, it's because the welfare state is on the march."----David Boaz, "Freedom in Crisis" Cato's Letter Summer 2009 Vol. 7, Number 3.

The bad news is that the Sermo forum for the ideas and beliefs of physicians is the only visible freedom movement now available to America's 991,066 non-federal physicians. (Source: Sermo Doc

We need to get the socialists out of political office before they ruin our great country. All we have now is a bunch of commies who take home a fat pay check paid by our tax dollars! Free enterprise is the way to go. Abolish all health insurance except for catatrophic health insurance. Everyone should be responsible for their own health care.

When a doctor is salaried, he/she works for the system, not the patient.

Salaried physicians is one practice model. It shouldn't be the only practice model, just as there should not be one payor or one choice.

Frankly, giving a lot of the administrators I've known in my career the pen to sign a doctor's check would be committing professional suicide. Particularly in smaller communities. I have experienced having an adminstrator tell me to not complain about something, or else..."Maybe we should look for another doctor.'

This economic blackmail of physicians already manifests itself in the form of sham peer review and the abuse of the 'disruptive physician' clauses in medical staff bylaws. Making all physicians employees would simply institutionalize this and expand it into private practice.

You know, I like America the way it is. If all these people want single pay, salaried doctor, medicine by bureaucrat, there are literally dozens of countries in the world that do it this way.

If we end up on salary, I'll quit medicine. I want the opportunity to control my own destiny. The more I work, the more I make. I would like to keep it that way!

Fine ... If I am to be on a salary THEN the Government will pay for everything else as well, including overhead, staff and malpractice. I would like to have a guranteed pension plus additional benefits like paid vacation and overtime, health coverage and disability and be represented by a union to have some way to go back to Washington and present my group's grievances to the governement, just like the Teamsters...I want to work a 36 hour week, have someone else be on call off hours or be paid overtime every time I have to run to the hospital off hours or if I have to be avaliable for emergencies. No more free medical advice over the phone for all neurotic patients who can resort to the ER or wait until the office is open and WAIT for the doctor to see them at a scheduled appointment for all their inane questions. I want to be able to stike if I feel I am being underpaid or exploited, and will never carry another pager for the rest of my career.See how much the American public willlike this kind of medical care... elections have consequences!!! They wanted Obama, now they will have to deal with the mistake that was made!

I agree with amdcu93 that just giving physicians a salary takes away the incentive to work. I coukl "take my salary", work 9-4 like any government employee and then open up my "practice" in the evening for "private" patients, thus creating a two-tier system like exists in England and India. Salary takes the entrepreneurship and sense of ownership out of practice. Will we also get pension and full benefits at retirement after working 20 years? That will cost a fortune and is the reason New Jersey is in such deep financial trouble now. I would however, like donatella, look forward to no more phone calls or essentially unreimbursed after-hours work.

Shouldn't attorneys be salaried. The time has come for national legal care. We shouldn't have to pay for our legal rights as they are our "rights"! We need a drg system to unclog the courts and make it an "outcome related verdict" . Make it easy on the overburdened courts, judges and attorneys who work so hard nights, holidays and weekends losing their beauty rest like us physicians. Let the taxpayer national legal care service pay for it. This could also be applied to businesses helping them to thrive creating more jobs, solving our presnt unemployment problem.

I didn't spend 12 years of my life going to college, medical school, and residency while paying out of pocket and taking out non-governmental loans just to become a government employee. To some degree we are all salaried. But, I still have incentive to work hard and reap those rewards. Moving forward, I do not see young adults choosing to be physicians if they are forced to become a government employee. What happened to the American Dream? I made decisions while growing up that have allowed me to succeed. I have gone from a family that was slightly above poverty level to being a successful and productive citizen. Yes Mr. Dean, please penalize me for not being a stain on society. You had better forgive all my debt too. I would like to see how this country would survive if the physicians united and stopped paying back their loans! Also, I would like to go to a restaurant, eat and leave without paying. That's what I have been dealing with while working in a small town. Pay me for what I think I am worth and we can talk. That is if you are willing to include major tort reform in the discussion as well.

No one has mentioned the 'domino effect' of salaried docs:

If the MD's are salaried, that inferrs they no longer own their practices.

Which implies that THEY no longer decide what to pay their employees.

Which implies that ALL nurses and techs will eventually be govt salaried and govt employees.

Which implies that the MD's will have NO CONTROL on whom they hire and fire (or their schedules, or whom they accept as patients, or whom they may discharge as patients, and so on).

In other words, I wonder how the nurses in the powerful SEIU Union in my town will feel about THAT? I doubt they'd be too excited to learn they're about to be govt employees....

People forget that at one time Dr Dean was the HEAD of the DNC! He's not some 'rogue' thinker on this--to my mind, he's reflecting the philosophy of the controlling party in the govt at the moment!

We should be VERY afraid of this man and his opinions: if we're put on salary, patients will be hurt as physicians cut back on workloads, retire, and in general sour on the profession. Salaries work perhaps in big major academic medical centers where many 'lifestyle'-oriented physicians practice. They DO NOT work in the community setting, where one must be a 'worker bee' rather than a govt-employeed 'drone.,' where patients need to be seen in five minutes and not five months!

Still, I'd agree to a salary if it would mean a <40 hr work-week with 6-8 weeks paid vacation a year and a limited schedule and no malpractice threat and all my expenses paid and little night or call duty and so on.....

Well, I don't believe that's the system of 'salaried physicians' the govt has in mind. So I'm agin' it!!

The good news is that Dr. Palestrant is a legitimate and knowledgeable spokesperson for these physicians, their patients and all freedom-loving Americans.
(see my 12.23 PM posting)

why do we even waste time analyzing an idiot's opinion.

I hope I get one of these senators in the trauma bay. I will have no problem denying them care and treat the uninsured in the next bed. We should all stop seeing senators, lawyers and congress people.

We need to stick together and fight for ourselves

We need health care reform but we need reform that emphasizes 1) a free market - price fixing hasn't worked for the past 4000 years - it is unlikely to work now. 2) Personal responsibility for health status -- patients who are obese, smoke, or who are noncompliant with standard care should be charged a premium 3) Physicians are not cattle - don't expect to herd us into all be salaried -- the 'unexpected' concequences of that will undoubtedly include: still fewer primary care physicians, a loss of incentive to put in a full day's work for a full day's pay, and overall lower quality healthcare. You still get what you pay for!
Isn't it about time physicians were brought to the table to work on these issues and take the politics out of it? This is really beginning to wreak of what the Boston Tea Party and other similar demonstrations of that day were all about - leadership making decisions on the lives of those who were in no way about to bow to the wishes of a king; and civil unrest was born.

We need health care reform but we need reform that emphasizes 1) a free market - price fixing hasn't worked for the past 4000 years - it is unlikely to work now. 2) Personal responsibility for health status -- patients who are obese, smoke, or who are noncompliant with standard care should be charged a premium 3) Physicians are not cattle - don't expect to herd us into all be salaried -- the 'unexpected' concequences of that will undoubtedly include: still fewer primary care physicians, a loss of incentive to put in a full day's work for a full day's pay, and overall lower quality healthcare. You still get what you pay for!
Isn't it about time physicians were brought to the table to work on these issues and take the politics out of it? This is really beginning to wreak of what the Boston Tea Party and other similar demonstrations of that day were all about - leadership making decisions on the lives of those who were in no way about to bow to the wishes of a king; and civil unrest was born.

Salaried physicians in the VA see whatever number of patients the particular facility tells them to see and that can vary (in psychiatry) from 8 to 16/day. VAs are under the gun to meet certain criteria, such as panel sizes. One facility gives docs 20 min appts for returns, 40 min for new pts and allows them 30 min at lunch (which is only 30 min) to return calls, to do other admin stuff) So don't kid yourself about working less for the same amount--and you generally don't have control over the scheduling.

The pay scale changed just as I was leaving, so I can't speak to that. Before that it was based on base salary, tenure, scarce specialty and geographic pay, board cert and being full time.

We need health care reform but we need reform that emphasizes 1) a free market - price fixing hasn't worked for the past 4000 years - it is unlikely to work now. 2) Personal responsibility for health status -- patients who are obese, smoke, or who are noncompliant with standard care should be charged a premium 3) Physicians are not cattle - don't expect to herd us into all be salaried -- the 'unexpected' concequences of that will undoubtedly include: still fewer primary care physicians, a loss of incentive to put in a full day's work for a full day's pay, and overall lower quality healthcare. You still get what you pay for!
Isn't it about time physicians were brought to the table to work on these issues and take the politics out of it? This is really beginning to wreak of what the Boston Tea Party and other similar demonstrations of that day were all about - leadership making decisions on the lives of those who were in no way about to bow to the wishes of a king; and civil unrest was born.

Why do we waste time talking about this 'idiot's' opinion?

Because if you asked the American Public, and those in govt to name ANY nationally-known doctor whose opinion they might respect, Howard Dean's name will be on that list! Right after Dr 'Oz' and right before Bill Frist's....

I do not disagree that Dean has an idiotic opinion--but I disagree that we should ignore it. It's a dangerous opinion that threatens our profession.

I do agree with being a hospital -employed surgeon.
I still feel free to manage my patients, many of whom do not have insurance. I do not worry about reimbursement, or even bother to look at the patients' "facesheet" to see what type of insurance they have.
Access to healthcare? Many of the private surgeons say they cannot see certain patients in their office because they have only medicaid; so they send them to me.
Many of them, I think do unnecessary procedures, and order unnecessay consults to other private docs.. (I'm guessing it's because someone wants new shoes,.)
I feel I do what is right for the patents because they are my only concern, money does not even enter into the picture. I do not get paid by shift. I get paid to do the right thing, and be there for my patients.

I drive one of the nicest cars in the doctors' parking lot, and live in a nice house. Despite a big student loan debt, I am finacially comfortable.

Everyone knows lawyers are greedy, and soon the general public will speak that way of doctors if you keep complaining about money, instead of the real issue.

.. and doctors in a union? forget about it.. it would never work even if were "allowed" I would never join. How do you go from talking about being a free thinking physician, to being a union guy like some auto worker?

Prez.Obama's Pay Czar will send a check to all the physicians
who sign up for this great healthcare reform !!!

Instead of putting us on salary, why don't we put all lawyers on salary? I wonder how they would like that?

Go ahead, salary me.

I'll work my 40 hours per week, and not 1 minute more.

I'll take every single government holiday off, as will my pager.

I'll take every single paid vacation and sick day that I can.

I will see exactly the number of patients/day that is mandated, and a not a single one more.

When a patient has severe pain, and an injection will help, I'll let them know I will submit for permission to do the injection, and when the ok comes through in a few weeks, We will hopefully call them.

I'll let the government handle my malpractice, so I won't give a rats-ass if anyone wants to sue me.

I will no longer have to worry about hiring, firing or disciplining employees, some government overseer will.

Rules and regulations will prevent me from performing most of the treatments I would recommend, but that will be the patient's problem, not mine.

Go ahead, salary me.

I work at an academic instituition were most attendings are on salary with some "in need specialties" with a bonus structure and it is a disaster. There is absolutely no incentive to get anything done on time because once 3pm hits its the next shifts problem. If I have a case that is delayed and the start time is anywhere near 2:30 it isnt going until 5pm. Clinic is the same, our REI guru sees 3 pts a day only on morning clinic and does 2 minors in PM. Hows that for reduced access to care.

I currently have a small private practice. I also have $200k in medical school debt left to pay, malpractice, health insurance, and office rent to deal with. I've also paid back almost $100k in medical school debt. I live a middle class lifestyle (no credit debt, few luxuries) and drive a beat-up old car. Is the government going to pay me back pay for the medical debts I already paid? Will they cover my school, health insurance, malpractice and rent? Or should I leave medicine and get a job in industry?

level1:

I'm glad that system works for you, but on a national level it would not likely work as well! I wonder how you'd feel if your workload suddenly doubled, your free time was halved, you had no say on your employees, and the young physicians you began to train were less intelligent or qualified than those in previous years.

Because that's what would happen in many parts of the country if ALL docs went on salary. What works in a few places--like larger medical centers--would be a disaster at a community level, where most people receive their care.

Obviously there are profound and complex problems with our health care system which require thoughtful, realistic, creative and enlightened decisions. Given the inherent heterogeneity of medical practice, grand, generalized and haughty plans are inane. Government involvement is generally abhorrent, and the initiatives of this administration and its apostles are vile.

drspuds -

Right on.

Bring it, socialists, just bring it. You will reap what you sow.

yes,we should be on salary,as long as they change everything else about the system. that includes cost of medical education,overhead costs,patients' expectations,malpractice insurance costs,drug costs,and our work hours. Fix all that and I would be delighted to work on salary,and I mean it. But you can't change just the way physicians are payed. The whole system stinks. It stinks for doctors,it stinks for patients. Stinks stinks stinks and it needs more than a band aid.

I forgot to weigh in the other day after I watched the interview. Dan - nice job in sticking to the real points while the moderator and Mr. D tried to avoid anything but what the National Enquirer would make a story out of. I loved your persistence at doing what politicos do best....change the subject to what they want. You played the game well and brought up just what you wanted to, what is important and what is important for the public to hear .....avoiding the canned attempt to keep Sermo as just another upshot. Stay true to the values, avoid the draw to become just another "AMA" - you have a good start.

Many physicians are already on salary. Witness the major clinics, the clinics being run by medical schools, hospital based physicians, etc. Physicians who are on panels that take Medicare and Medicaid and 3rd party payments are already, in a manner of speaking, on partial salaries. Let's get the incentives to do testing out of the practice of medicine. We need government involvement, we need tort reform, we need more internists and pediatricians and family doctors and fewer specialists providing initial patient care, we need controls to stop the excessive profits by the medical insurers, we need more imaginative and appropriate and fair malpractice insurance, etc.
Let's get started in a proper direction.

To wcyrusmd. We are not ignoring the cost of medical care and the issues that engenders for our economy. However, the people being shortsighted on this issue are those who are pushing for massive 'reform'.

First, let's examine two premises that too many have bought into, that medical costs are out of control, and that physician salaries are a big driver of the issue. Medical costs are going up because what is provided to patients is continuously evolving. If we provided what we had available in 1990, at 2009 prices, there would be no increase in costs, and likely a significant reduction in costs. We have newer treatments, such as intracoronary stents, drug-eluting stents, newer tyrosine kinase inhibitors, etc. that just weren't available then.

These drive up costs, but the alternative is to not have innovation and improvement. Look at what has happened to the size and sophistication of pacemakers and AICDs over the past couple of decades. Also, the controlled trial, outcomes driven indications for AICDs have also expanded significantly. So, more patients getting more devices, and getting newer generation devices equals increased costs.

We could have a debate about whether or not everyone should have access to the 'best' medications, procedures, and devices, but this is a philosophical debate that is apart from the issue of what actually drives medical costs.

I think we need to do a better job laying out the options to patients, and letting them participate in the decision making with regards costs. To do that they need to have a stake in the costs. Arguably some newer treatments and approaches have only relatively minor incremental benefit. If these come at a markedly greater cost, perhaps in conjunction with the patient and in the context of full disclosure the cheaper only marginally less effective therapy could be chosen.

As a general comment, the biggest impact on public health in this country would be to reduce the average weight and improve the diet of Americans. This is not a 'medical reform' issue, but one of public health and personal responsibility.

I worry that we will throw the baby out with the bath water. Those who think of themselves as 'altruistic' patient advocates and who, on that basis, want to start dismantling our medical system need to cautiously examine what the consequences will be, and be honest with themselves about why they favor these changes, including the impact of their own ideologies. For the record, because of the setting in which I work, I am salaried, but that is my choice, and it is a choice that should not be forced on anyone.

Contrary to Dr. Dean's position, if every physician were required to spend time in private practice, and a solo primary care practice, managing his or her own practice and business, then every physician would have a greater appreciation and conceptual understanding of the mechanisms of providing health care and cost per physician involved. Also, if every physician had to practice for a time in a remote or rural area in the above setting without all of the convenient bells and whistles of large medical centers, he or she would have a greater appreciation for what is actually and absolutely essential for the care of patients.

Physicians who haven't been in and specifically run a private practice have no concept of the mechanisms or costs involved. Physicians who haven't practiced outside of academic settings have no concept of providing the most efficient and cost effective care to their patients. Without these experiences, and even with them, I would venture to guess that the vast majority of physicians have no idea what each order they write means in terms of cost to their patient or the patient's payor outside of the physicians' own fee or salary and no physician who hasn't been in private practice has any concept of the cost of delivering health care.

What physicians are paid is a small part of the cost of medical care, but through our orders, what we allow others to charge creates the rest of the cost directly or indirectly.

having joined paid group as surgeon as result of personal tragedy, I still have the work ethic.
I "eat what I kill"
I became nominal med director of group due to seniority and interest.
I saw what happenned when a doc was recruited on salary.
1) paid more than others
2) had little work ethic (shift work.. 9-5, mega paid absences/vacatiions)
3) left at end of contract which has left huge hole in our coverage.

Howard Dean's plan assumes that healthcare costs are out of control because doctors make too much money. He's clearly out of touch with reality.

I spent 7 years in academic medicine on a salary. The work I did generated two salaries, which was typically 2 standard deviations above the money generated by the lowest-generating member of the department. Lesson learned: why work hard if you get salary ?

Now I'm in a private practice where I earn my money based on how much I want to work. My patients get great one-on-one care and my family actually sees me for dinner and on weekends. I also choose to care for every patient that walks through the door, regardless of ability to pay. Can't do that if the boss has you on salary.

You can't buy your life back. My patients have taught me that. My quality of life is more important to me than my income. Not being on salary allows me the freedom to balance work and life as determined by the needs of my family, my patients and myself.

of course he is going to say that...having an MD after your name doesnt mean you are a practicing physician taking care of sick pts day in and day out?! he a damn politician thats all NO SUPRISE.

level1: Don't misunderstand having the ability to make money with greed. Name me one business man that doesn't want to make money? I want to make money. I am a hospital based contracted physician. I read everything that comes through the door. I should reap that reward. I don't turn anyone away. But, if the limit to my income is set by the government and not by productivity, you can bet this hospital would have to figure out how they would justify to the government having more than one radiologist here. That would be a detriment to this great, small community. I would not work seven days a week and certainly would have limited call. The fact that the government would be watching my hours would effectively close this hospital. Unless the government wants to pay overtime! Also, there is a shortage of physicians here. How would we get a qualified/ board certified radiologist to join me when there aren't enough to cover the country as it is. Some of us do work our tails off because we love what we do and are good at it. If that means I make more, don't I deserve that? I really don't care if others think that is greed. Those are the people that screwed around in school and want to complain about another's success. I worked hard in school to get a good residency and am working even harder now because(as I said above), that is the American Dream.

To shadowdoc85 . I absolutely agree with your comments. Every single one of us has the right and freedom to volunteer our time, and clearly many do. It is, however, in a free society, the right of the individual to decide who they want to work for and what they want to work for. Most elected officials couldn't even begin to make their way through basic science education and medical school. Most of us do not want to work for the government. Most physicians who have spent any significant time in a VA hospital during training or otherwise know full well how bad government run health care can be.

Sure why not a salary. As long as we also establish and cap the salaries of every employee/CEO of big Pharma and medical device company, insurer middleman, hospital CEO, and malpractice attorney. We have been under de facto wage and price controls for 2 decades. Let's let the rest of the sector catch up. Don't hold your breath.

I love what mbasaran said. The medical profession and most importantly patient care will suffer at the hands of the politicians who are often lawyers who make the laws. I agree...want doctors to be salaried? How well have studies shown the productivity of people who were not provided an incentive? Just look at ALL gov't agencies. They are guaranteed a salary even if it takes them 1 month to complete a task. I was just told by the IRS that after my change of address was punched in...it will take a MONTH to process before they can confirm that it is updated. So you now want gov't to run health care....HA I want to know if Michelle Obamas mom wants and is willing to be part of the "socialized" health system...and the "duty to die" as we age over 65. Don't want to get off the topic. Long and short of it look at all the unions...they asked teachers to give an extra 10 min a day and they started whining that they were going to fall over with all of the work. Yes salary doctors and then as a gov't worker we should NOW get a pension so all of the self-employed doctors won't worry about retirement, get months of vacation, get my medical school loans paid for...pay my malpractice...and my 70% overhead...the govt will pay for my staff and their health benefits and watch the access to doctors will suffer. The brightest people will not go into medicine and there will be less and less doctors available to see everyone and I WILL then take the appropriate time needed to see pts effectively which has suffered under the currnet system and therefore will see less pts. They THEN will tell us that we are acting unethically in some way, but will certainly decrease mistakes made if ample time can be spent with each person. What doctor wouldn't prefer seeing 1/2 the pt load...not working less hours...but giving better quality care...again this will in turn decrease access. They say we need to be more efficient...HA Who could be more effiicient tha n us. I see a diabetic with 5 co-morbid illnesses...write all of their RX....in 15min...I would love to have 30min...If I did that I would go out of business b/c overhead is too high.
I truly hope we get some reform...it needs it..but STOP always BLAMING doctors for the problem. It is probably the only above board profession with people who actually CARE about other people. We took an oath ....and WE are the only ones who have fought for pt care. Unfortunately our president always paints us in a light that we are all driven my $$ and not ethics....Don;t look in the MIRROR Mr President

A Price waterhouse study for the Federal GAO in 2008 cited Doctors' fees to be 33% of the healthcare dollar. The same study cites that the insurance comapnies profis were only 3% of the healthcare dollars. So if Wellpoint made $61.2 billion last years this means they spent $2 trillion on providing healthcare to their insureds. ($61.2 billion divided by 3% = $2 trillion) Aetna made a similiar amount as did US Healthcareas did Cigna and if the their profits are added together this amount to something in range of $150 billion. The problem is the National Coalition on Healthcare reported that the US spent only $2.4 trillion for healthcare. Obviously there is more spent on healhcare than reported or the study is flawed or the insurance companies spend less on healthcare and actually make more than reported. If I was going to make a killing in healthcare I would shoot at the heart not the toes. Fixing our salaries is equivalent to shooting at a toe. Shoot all the toes The healthcare will have a difficiult time standing.

No.

Physicians as salaried workers isn't a bad concept when applied to individual physicians like level1 or me, who can be hired and paid based upon our skills and value to a particular healthcare system. Where the process breaks down is when the government pays or dictates the salaries. Then, physicians become commodities and all trauma surgeons or ED docs (or whatever) get paid the same, regardless of how hard they work or how good they are at what they do. This leads to mediocrity and a very average (ie. government employee) level of production.

It puzzles me that the debate has become one of how much doctors get paid when that is such a minor and (comparatively) not rapidly increasing percentage of our health care expenditures. In fact, the most prominent cause of increased physician pay has been that WE ARE DOING MORE WORK!!! I don't think that the same correlation can be found in the explosive growth of CEO pay and administrative staff size for hospital and insurance companies over the last 30 years.

Many of us have been salaried at some point in our careers, and that is the trend in the future, but only in the case of the VA does the government employ many physicians. If we all became salaried I assume it would be the government that paid the salaries, and of course they would pay overhead and provide you the clinic space, etc., just like if you are salaried now.

This is NOT going to happen, of course. Britain is the only major country where the docs are salaried, as far as I know. Just because Howard Dean said he thought that was the way to go, that doesn't mean it will happen. NONE of the proposals that the congress is voting on include salaried physicians.

Shouldn't we be focusing on the current proposals, not something like this?

If salaried, they better socialize the drug companies, as my patients cannot afford their drugs. So my hide is dried and the drug companies go on to graze? I don't think so.

Second, the best practice would be to have a clearing house of data tracking patient compliance, not doctor complaince, and penalizing those who don't take their doc's advice, don't take their meds or don't follow up. Why am I penalized for that???

I'll take a salary and be happy to reduce the demand on my time if I can reduce my overhead as well. I can't see how that will happen with the new health care plan. Bodomo makes a great point too. Docs are forced to go into debt to attend medical school. If everyone goes on salary, how do you expect doctors to dig out from a $250,000 loan? We'll still be paying it off when we're 75! When are the idiots at the top going to do the right thing and incentivize doctors to provide preventive care? The current reimbursement model sucks. Congress has no clue how to fix it nor does the Ex Governor.

Two faced politicians! They would never put themselves on this program, and they would never even bring up putting salaries on attorneys. They will pretty much cap everything else.

The idea that physicians should all be on salary implicitly accepts the idea of socialized medicine--that physicians are property of the state and their minds and labor belong to the state to dispose of how it chooses.

Absent the principle of individual rights, this is the kind of ridiculous haggling we get. Should we allow doctors to work 40 hours per week or 60, or 30? Should they make $80 per hour or $100? Should we pay everyone's med school tuition? What ridiculous bull*&%t!

Physicians, like every other individual, have a moral right to their own life, property, and labor. No one--not Howard Dean or Barack Obama or any Republican, or anyone on this thread for that matter--has any right to make such decisions for anyone but themselves.

I second andrewldoe's motion and urge everyone to read:

Sermo Doc

yes. all physicians should be salaried but to the salary of wall street junckies
or stupid ball players.

First form a union, call it "National Doctor Association".
Second get an agent to bargain on my behalf.
Third ask for a fair compensation, no different from all those athletes getting millions!
Fourth if our demands are not met, Strike like in the NHL.

The only benefit of being on salry by the Fed is that it would be a nightmare for the trial lawyers because then lawsuits would be capped. Who is going to pay for the dept incurred by medical students? Dr Dean has not seen a patient in years and I can see why!

I would love to be salaried, just as over government employees, and have , 1 hour lunch breaks, all weekends and holidays off. No nights. No work after 4:30. And most minor holidays off , along with paid vacation. Also paid sick time and also PTO when you really just dont feel like working. Or maybe better yet, I could just turn my phone system on so no one could ever get in touch with me when the have a problem, like the other government agencies.

The last time I checked, this was supposed to be "The Land of the Free." Free to make our own decisions and not have the government making those decisions for us. I went into medicine to of course help our fellow Americans but also so that I could have my own business. I think it is fine that some physicians want to work on a salaried basis; I am not one of those. I do believe that there should be a profit in medicine and the government should not be telling me what that profit is. If I charge too much, the patients will no longer see me. If I charge too little, I can not afford to stay in practice. Insurance companies are businessess too. If they want to pay their CEOs millions of dollars, that is up to them, and I don't have to buy insurance from them. My point is this.....we are all individuals and the majority of us are able to make our own decisions; therefore, get the government out of healthcare as all can tell by their history, they have done such a fine job so far with Medicaid and Medicare, but that is another story.

I worked at the V.A. as a resident.I was in the U.S.A.F. for 3 years.Never again-never,never,never.

Where is the AMA?. Obama says that a doctor in making the diagnosis of tonsillitis will up code to a tonsillectomy to make more money. Making a diagnosis and performing a tonsillectomy are different. One is a diagnosis and one is a procedure. Obvoiusly the president doesn't understand medicine and the difference between thinking about something and doing something. He has acted "stupidly" Putting all physicians on salary is tantamount to saying that all Americans should drive care made by GM. It's like saying buy an American car knowing that most of the cars are made in a foreign country. It is a all a fascade.

I really enjoy the VA examples-in the VA, the doctors would leave at 2-3:00, would do the absolute minimum and patients would wait weeks to months for testing. You could walk into a clinic waiting room and see people waiting for hours to be seen. Would this happen in private practice-not if you wanted to continue to have a profitable practice. Socialization begets laziness and doctors in general are not a lazy group. We want to work hard and be rewarded appropriately.
If the government thinks they have a problem with physician shortages right now, try socializing things and watch a given physician see half the number of patients in a given day.

I am coming from a foreing country with socialized medicine and free medical attention, but I went to private schools and all the people I know have their own private medical insurance. That tells you something, no?.
The UNION is the best alternative to fight this kind of proposals. The nurses are associated in an union and we all know that they are very powerful, so that's the only way to implement our own regulations.
If we create a union, we can create rules in terms of salaries, benefits, taxes, etc. We can state that no MD will work for less than ...., no MD will work if ....... .
The best way to fight a polititian is with politics!

Put all docs on salary. We can do shift work and go home at quitting time. Time and a half for evening call and double for graveyard. Medicine will then be just another trade, instead of a learned profession. Malpractice insurance would have to be one of the benefits. Of course, medical education would have to be subsidized, too. Grads wouldn't be able to pay off $150,000 to $200,000 of debt on a government salary.

If stagmd thinks the UK model is so great, I wish he could talk to my friend in Scotland, a retired teacher, who nearly died from a massive upper GI hemorrhage while he was in a 6 or 7 week queue, as they call it, for an upper GI series. A scope procedure was not available at all. Possibly the saddest aspect the story was the fact that this has been typical of their system for so long that he didn't question the delay and just accepted it as the way things work. And how many new hospitals have been built in the UK since WW II? Not too many years ago the answer was none. Has he ever talked to a typical UK G.P. about the size of the panel he has to maintain and the number of patient he has to see a day to survive? Get real!

hello communism!

LET ALL THE HUNGRY DENTISTS ALSO BE SALARIED.

Looking at many of the above posts, salaried physicians see advantage. Not only that, they seem to think those of us in private practice deserve sympathy! But don't you salaried docs see why life is easier for you? You're subsidized!

Interesting comments. Salaries without incentives are unlikely to improve the quality of care. In my training in the American College of Physicians there were several models discussed to insure productivity and rewards for it, on top of salary.

I am sort of a market driven kind of guy who believes like Adam Smith that self interest is not always a bad thing. Perhaps, the most driven by self interest group that is allegedly on salary is the politicians

I am already salaried by a publicly (not govt) held corp. But at least we have a bonus structure, stock options, and I own shares in the company.

My Dad is an FP in Vancouver, BC. They aren't salaried and get fee for service based on the negotiations between the provincial govt and medical college/association (re: union). The catch is, they are limited to the number of patient's they can see per day, have to take mandatory holidays and if they make over a certain amount, there are "clawbacks". Oh, and if your peers make less, they take it out of your paycheck also.

He always said he should have moved down south but I haven't had a chance to ask what he thought about it recently.

I could possibly see a salary set according to how many patients a primary care physician had in his/her medical home and have the salary high enough to cover overhead expenses with us determining how much we were willing to spend on rent, salaries, etc. Hard to imagine how the other specialties could be on salary. Being on salary would take away initiative for primary care to handle problems rather than to refer.

Placing physicians on a salary is a violation of the our Constitutional rights, which guarantee life,liberty and the pursuit of happiness. Taking away the ability of MD's to make a living by placing them on salary seems unconstitutional to me.

Lots of physicans are already on salary. Organizations that hire physicians have incentive structures to promote productivity, like any business. I think that the biggest improvement in the healthcare system that could be made would be to tear down the barriers to unionization. Then physicians could have an effective (ie not the AMA) collective voice.

"And all doctors should be required to donate at least 10% of their professional practice to indigent care (unless, of course, everyone finally gets insurance). Indigents and the working poor without insurance deserve care too, and the richest doctors (and dentists) are not providing it. "

As a physician in Arizona, I can assure you that more than 10 percent of my practice is spent giving free care to indigents. Funny thing is..I dont even volunteer for it. There are so many poor illegals that are breaking our system, that we dont get paid for more than 60 percent of what we do in the first place.

Fee for service is the backbone of American Medicine. It is not broken. Stop believing the hype. The vast majority of legal Americans are insured and like their health insurance plan. These guys want to wreck the entire system for all 300 million patients to expand coverage to the 20 million or so that do not have it. (the 45 million number you hear is a complete kinard...more than half of those are illegals and young adults who CHOOSE not to have health insurance).

If you want to know why Americans spend so much money on health care, dont look at the providers...look at the customers. The American population over utilize the system....going to ER's for malladays that are quite benign or dont exist. The american people live a sedentary lifestyle and have terrible eating habits (we are the only nation where food is so plentiful that poor people are fat).

Saying America spends too much money on healthcare and then blaming doctors is like saying Americans use too much oil...and then blaming the oil companies...(oh waite..we already do that)

"The best way to fight a polititian is with politics! "

Well said Dr. Patricio!!!!

There is not enough money in the US treasury to buy out all the private practices in the US if they decided to make us salaried/government docs. Who in their right mind will be a salaried doc and shoulder the expenses/overhead of a private practice????

The comments are overwhelmingly against governmental management of physician practices and provision of care, and with obvious reasons. (See various comments above.) Even if we all maintained the altruism with we we chose our vocation, the fact that the government is the most inefficient provider of services is an inescapable reality.
It is ludicrous to expect the level of care to remain constant if the incentive for working hard is eliminated. Furthermore, the personal touch (that most of us provide for our patients) would be lost if we are reduced to "government employees" (or for that matter "insurance company employees"; for proof of that, one need only view the patient satisfaction of HIP patients in NY compared to the satisfaction of traditional indemnity plan participants). There is a reason why the expression "close enough for government work" has been a staple of the verncular. As an obstetrician, would I be limited to 40 or 60 hrs a week? Who will be responsible for delivering our patients in the middle of the night. The shift to laborists is not good for quality of care. Indeed there has been no prospective study showing that limiting Resident work hours assures imroved outcomes; why would limiting private doctors' hours be expected to imrove care either?
In terms of provision of healthcare for the unisured, most economists will provide data that support privatized solutions, not governmental oversight. To wit, the government typically spends less than 50% of alloted funds on the providers of a service (that is in any area) while spending over 50% in management and support staff. By contrast, most reputable charitable organizations spend at least 80% on the cause, while limiting administrative costs to less than 20%. Why not let these agencies be responsible for providing healthcare for the uninsured. Revenue for their agencies would come from charitable donations (tax breaks for the donors, in keeping with current guidelines) instead of inefficient elevation of tax levies.
I am certain that together, we clinicians could develop more effective and practcal solutions to the obvious need for healthcare reform.

Salaries: Likely will make any of us lazy, me included. Been there - done that and now with the headache of running my own practice, I must be nuts, but I like my own practice as difficult as it is, even though it is likely easier than the FP I use to do years ago as I now do OccMed with a lot of complex cases, legal, etc. It has it's own headaches. Salaries work two ways. First it allows employers to do such things as cram 30-40 patients into 4 hours and reduce the quality of care and second it allows docs to possibly get a bit lazy...i.e. no overtime pay. We are taught to do the job no matter what.....it goes with the territory. It use to be that compensation for hard work, long years of school, etc. was reasonable and one did not mind the extended hours, but not any more, especially for primary care thinkers. So, secondly, when salaried, we end up conflicted with traditional values, that hopefully we all still have, and the "business model" that has been perpetrated over the last 20 + years. Salaried at $200k a year isn't too bad, maybe $350k for a specialist, but at $150k or less a year is less than Dr. Dean as a "part-time" congress person....plus we don't get to vote our salaries up and still have to save for retirement. "The first thing we do, kill all the lawyers." (Shakespeare) Then we would empty out the dead wood of the government. Revolution not evolution. I like the idea noted to have Sermo write the HealthCare Reform Bill.....and suggest a "real language" model for the public to understand. Sorry I cannot give a solution, I need to see patients and struggle to get enough business to keep the lights on, etc. - and that is a real statement not just rhetoric.

AS a rural solo FP......if a salary is to be mine (which I've never had), then all of the expenses, including staff salaries, lease, treatment materials, vaccine costs, ultrasound machine, CME costs, license costs, professional dues, payroll taxes for staff, soc. sec. of staff, utility bills (cap and trade, you know!), employees' IRA matches, unemployment INS payments, Malpractice INS payment, school loans, EMR costs, etc.....must also be paid by the government. Then, ....being salaried now....how many patients must I see per day to receive my government salary? What a stupid, ignorant statement by Dean! Democrat "fixes" are mere socialistic band-aids,....or worse yet, camouflage.

The biggest problem with this discussion is that we have a bastardized system. On the one hand we have he federal goverment establishing a fee schedule but we have no cost controls. No other industry has a fee schedule. I pay what my plumber charges. He can charge for a trip fee & after hours service, etc. When I go infor a acute MI PTCA in the middle of the night, I get the same fee from Medicare as if it were an elective middle of the day case. Our overhead is skyrocketing & we are supposed to convert to EMR. If a company had to expend 10% of revenue on new infrastructure, it would pass this on in charges to consumers. But wait we can't, we have fee schedule. Then there is tort reform.

I say either go to a free market system or go to a complete socialized 1 payer system. However for the later, 1) someone else pays the overhead including a nationalized EMR 2) someone else pays for MD education - you can't have student loans in this kind of a system 3) overhaul malpractice to a tribunal board sort of like workman's comp & make sure our salary is commensurate to our years of training & experience.

The biggest problem is the current system is only part way. For real reform you need to go all the way - either way but do it right.

CAN WE PLEASE GET HOWARD DEAN TO SIGN ON TO SERMO..IF ONLY TO MAKE HIM UNDERSTAND WHAT PEOPLE THINK OF HIS SOCIALIST IDEAS?

I would agree to a salary, commensurate with my educational investment, training, and years of experience (newly minted attorneys, by the way, start out at $160,000/year these days fresh out of three years of law school, not four years of med school and at least 4 years of residency !) if the government agreed to paying my ever escalating overhead, malpractice, own health insurance ($15,000/year for my family of 2 as a small business), etc. It is ludicrous to limit our remuneration unless there are limits on all of our other expenses. I am now in private practice. When I started out, I did work part time for the VA (an out-patient clinic). Saw several old cronies with flasks of scotch in their desks, a few who never laid hands on patients (just refilled prescriptions), etc. There are some excellent VA facilities, where excellent medicine is practiced, but salarying everyone does open the door for incompetence, inefficiency, and just plain indifference.

As a certified card-carrying WORKAHOLIC, taking my own OB call 24/5 Plus 1 weekend a month, I think the idea of me working my ass off for anything other than Eat-what-you-kill is crazy. There has to be some incentive. Been there with the "salary" thing and discovered that there are plenty of people that are all too happy to stop working at 4pm and "check out" to the covering doc, call off to go see "emergency" movies on new release dates, and let those of us who work hard pick up their slack because Hey, We're all getting paid the same anyway... No Thanks.

I would agree that in some circumstances it may work well to salary. Surgical & Call-Heavy specialties, no way.

I see 2 big problems with physicians. One we have been to isolated from each other. most of us do not know how to unite and have any semblence of a unified voice. this is probably becvause most of us are independent thinkers, self starters, not interested in "good enough". Secondly, there are barriers to forming a union. the antitrust legislation would have to be over-turned in our case. good luck geting congress to go along with that.

I'll support any system that compensates cognitive skills more than fine motor skills, and long term management of chronic disease more than piecework

I would be happy to accept a salary to provide a specified number of hours of care weekly to patients who are enrolled in publicly funded payment schemes.

I would also be happy to provide care at other times to people who want to pay me cash.

Waiting list for option #1 - not my problem, I give them their 27 hours/week.

Waiting list for option #2 - "we can see you today".

Legal defense (offense) is a right, right?

I think all lawyers should be govt employees and on salary then.

I would like someone from federal government to answer this question. Why would I go to medical school????? if at the end of so much studing where i have to sacrifice my family life have $200,000 in loan and have no time for real life can not have all the weekend off, have huge liability for the practice and not being able to make good living. ????

Here, let's try this....... An automatic 15% reduction in ALL government spending over the next three years, with the ONLY exceptions being: 1 - military, 2 - medicare, 3 - homeland security, 4 - ___? one more/your pick____. Then we freeze income taxes once again, and do so for a minimum of 10 years,...to provide a security needed to bring about an increase in spending and investment in new businesses. Tell the congress persons and senators that it is LAW / mandatory that they READ ALL LEGISLATION before it can be even discussed. Then it is put out for the public to read. Then.....the voting begins. NO EARMARKS....NONE. Then, a true and verifiable "balance of trade" must be put into place, and we agree to not join in ANY treaties with other countries that have to do with this, so-called "global warming"....or...."cap and trade". First, prove to the American People that their human-related CO2 emissions have a real and scientifically measurable effect on any NON-CYCLICAL climate change. Prove it. Ready? Set? Go!

I think as a HUMAN we have a right to choose whether we want to work on salary or we DONT.

For God sake this is America -people can choose the way they want to work.

DOES DEAN live in America ? or he forgot the concept of DEMOCRACY.

To me the question is really quite simple in this whole debate: "Is making the system more complex (aka government run) going to make it more effective at providing care and be less expensive?" Even the village idiot can answer that question.

obgyn15

I would accept a salary like professional athletes get with the bonuses they get as well if I do a good job.

I was salaried working for the state.I was able to budget our finances with 4 children who finished graduate schools at universities without loans.I had to work hard but in the late 80's and mid-90's $14o,000 yearly was enough for a family of 6.Now I am on pension and medicare benefits of which shares was deducted from the monthly salaries. Of course our life was not luxurious at that time.Now we live comfortably with what we receive every month.

There is no reason to even consider salaries for all physicians. Physicians are independent professionals and we will remain that way as long as we insist on it. There are plenty of salaried jobs for those that want to go that route.

The selling point to the public, that is we do more because we get paid more and that is significantly increasing costs is unproven.

Certainly, if the goal is to turn us over to hospital systems, that should be fought at every level.

What the public will get if we are all capitated is less service and more use of non-physician extenders.

worst thing i did was to vote for obama.howard dean is a jerk i am glad he never got elected.who will pay for doctors loans.democrats suck.

IF FEDERAL has to fairly pay the doctors their salary - then probably there Health BUDGET will go up by a trillion dollar more. Otherwise they have to torture the DOCTORS and one DAY - there will be no DOCTOR - and people will be going to law firms/politicians for treatment. IMAGINE THAT.

If physicians are salaried, several criteria must be met, including:

1. Shared liability with whoever is paying the salary
2. Salaried physicians should not have to worry about running a business. All overhead, practice management, etc should be covered
3. Each individual physician will set their own hourly rate based on their experience and local conditions and then negotiate.
4. Medical eduction costs should be subsidized unless salary standard are high enough to cover average debt

I think there may be a way for physicians to actually make more money if salaried IF we retain our autonomy (in decision making) and are able to negotiate freely. In doing so, we would need STRONG representation so that things are not shoved down our throats. We decide how much we are worth based on experience and what we bring to the table.

At the end of the day, the healthcare system cannot function without us. We hold the power.

The troubling reality is that physicians will continue to see declining reimbursements with fee for service arrangements. Health plans look at what they pay us as "medical loss." As reimbursement goes down, volume goes up until we're all seeing 50 patients a day to make ends meet. This kind of fee for service arrangement is not sustainable. Health plans ain't our friends.

My comment disappeared. Sorry I do not want to repeat what I said.

I've worked on salary, at a state mental hospital and have seen first hand the results of such a system. A librarian appointed administrator telling my NP's to commit illegal acts because "we're the government and we dont' have to obey the law, we're immune from prosecution", the unbelievable waste of taxpayer money spent on receptions, meetings, vehicles and landscaping to impress politicians whose names were on "their" buildings while patients could not even get the basic essentials like soap or clothing because "we can't afford that", speciality medical referrals denied due to cost, unstable patients discharged simply to make length of stay shorter again to impress bureaucrats with what a good job we were doing. Support staff turnover was extremely high due to poor pay, understaffing and dangerous work conditions, poor training( they'd send the housekeeper to CME conferences and deny RN's who "didn't play ball"). Administrators made clinical decisions on patient care even though they had NO clinical credentials and told medical staff to follow their directives or be fired for insubordination. The "Best" state employee was the one who kept his mouth shut on all these and other atrocities and kissed up to the administration, generally resulting in a state salaried physician who goofed off, abandoned patients to play golf etc and who could care less about actual patient care. To cut to the bottom line you end up with poor care and the ehtical well qualified physician leaves the system to the worst physicians who care only about collecting the salary with the least effort possible. Is this the kind of healthcare system we need for the entire country? I DON'T THINK SO!

I think we should turn the U.S. in to France or Sweden. A good first step would be to put all physicians on salary with an incentive bonus structure. Also, no physician should be allowed to own medical equipment which costs more than $10,000. Healthcare should not be a for profit enterprise.

The issue is not salary vs. no salary. Its whether the system allows incentives for quality care. I have seen lazy docs that are not salaried and who cherry pick like crazy. I have worked in a VA that is salaried but allowed a variety of incentives including getting boards, high ratings, patient volume which led to more funds to the service, and because it was academically affliliated allowed incentives for getting clinical trials and non-Va grants. We were able to recruit quality hard working physicians. As usual the devil is in the details not the label.

Last night I saw 4 pts/hr for 12 hours. the national avg is 2.1 pts/hr and would likely be the standard set by the feds. my collections on billing is 27% because of the urban area in which I live. I have to make up for in volume what I miss in collections. If the govt puts my on salary, it will be markedly less than I make now. I will see the minimum number of patients to get paid and then kick my feet up and serf the net or work on my golf swing. Right now, I work my tail off for 12 hours and come home completely exhausted, but feel that the day is worth while because I took care of so many people. However, I expect to be compensated for the amount of work that I perform. Otherwise, I will make my work performance equal my pay

First, all doctors who are toying with the idea of retiring, or going part time, will do so.

Second, the medical school graduate pool will begin to dry up; and those who do still enter medical schools will be of lesser talent and dedication.

Third, many doctors will no longer put the same effort into patient care that they do now--- will not go the "extra mile" for their patients. No extra patients will be "worked-in" to a busy office schedule; doctors on-call will do the absolute minimum to get by; the incentive to stay current with medical education will decrease; collegiality between doctors will decrease; relations with administration will sour even more.

Fourth, the pressure for "extenders" will increase dramatically and, come to think of it, the push by the government to go to salaried physicians may in fact be the first step in a plan to replace most of them with "extenders".

Fifth, the overall quality of American health care will inevitably decrease.

I'll take the salary that Senators and Govenors like Dean get. And I'll take the free medical care, no deductibles, and supply me with an office and staff, pay my travel expenses (even if its just to go home for the weekend), and lets not forget the free car and expenses, and just like the government, make me unable to be sued!

Ok, send the checks now...

Ouch.
My brain just exploded.
Is there a neurologist in the house?
(And how long will I have to wait to get some help?)

Maybe I can teach chemistry at a commmunity college.

This equals slavery. Fuck these people that want to enslave us. We should eliminate all governmental and private insurance and place health care costs in the hands of the people. Health care should be a relationship between doctor and patient. Those that cannot afford it, die. I'm fine with that. It is a reality we must accept to move forward.

I can't believe how passive our profession is being as the government and big business destroys our profession and income.

Let's go ahead and give salaries to lawyers and bankers and see how that will work. I would think malpractice lawsuits will drop drastically !

I never realized how many crazy people there are in the medical profession. All these doctors ranting and raving, and their the ones that got us into this healthcare mess in the first place. And I love the ubiquitous "go to the ER" posted hear, like that doesn't add to healthcare costs. Myopia, all of you.

There are two options for healthcare reform, if they want us to be salaried:

1. Salaried physician with following stipulations
A. Pay for all overhead cost, pay for education loans, regulate malpratice etc( as everyone mentioned)
B. Expect lower quality of healthcare ( That is a given), unless it was incentive based salary

2. Free market healthcare ( as mentioned previously)
a. As physicians we need more training in the business aspect of healthcare
Can someone tell me if they were ever taught about billing in medical school or residency, YET we had to so many useless rotations in medical school particularily during fourth year...

b. take out this CPT coding crab, which I don't even have a clue how it works

A physician can ethically contract only with his/her patient. One can not serve two masters. One can not serve the Gvt. and the patient with no conflict of interest. Our managed care contracts are in fact unethical, as they add a layer of distraction to our interactions with the patients we are sworn to serve.

And PS: since so many Americans absolutely depend on cars for their work, and indeed for most aspects of their lives: owning an automobile should be a right, not a individual privilege; car dealers must all work at government salaries or, better yet, the entire auto industry should be socialized. Thus all auto workers, car mechanics, parts distributors, oil companies, tire companies, gas station owners, etc should be salaried government employees. All car models should be standardized-- in fact only a few models should be allowed, and all aspects of their construction and mechanical features should be strictly controlled by the government.

Next, since all citizens need clothing, all clothing design, manufacture, and distribution should be government controlled....

ajaymd: When you go asking for a job with the government, you cannot stipulate conditions! That is why some of us prefer to be left alone. Insurance or not I''d like to work on my terms. If unfortunately the Government goes ahead with Dean's idea of socialism, we will be like France/ Italy with over 25% of docs either under or unemployed. Of course we will all have a lot of free time to do other things. ..

WOW! If I were on salary I would stop running around trying to do as much as possible. I would work normal hours and no more. I would get coffee breaks and lunch. I would not worry about "how to pay for vacations" since those, too, of course, would be paid. I would let someone else worry about the overhead and what to do about support staff not doing their jobs. I wouldn't even have to worry about whether the ins companies denied claims! And anything I didn't like about my employers and their job I could join others and legally form a union to make "change" happen!

Let's face it: if doctors were all salaried employees we'd join the ranks of most of our fellow Americans in professional occupations!

Now if only we could get those lawyers who sue doctors to be put on salary!

Most humans are unable to over-ride the basic drive to work for reward. When the reward is consistent regardless of increased effort, most will resort to the minimum effort to ensure the reward. As physicians, the reward we work for includes but is not limited to monetary compensation. It also involves patient appreciation, intellectual stimulation, personal satisfaction over solving a complex problem, and respect from society. However, as we work harder for less money, the financial considerations have begun to take a larger role.

In my community, this is how it has worked out. My group is physician owned and pay is based on production - we do fairly well, work very hard (see 40 in summer/60 in the winter), and have night and saturday clinic hours in addition to call. We see 50% of the kids on medicaid in a 4 county area, and will see any kid that is sick they day they call for an appointment. The other peds in our area are all salaried, with their practices owned by hospital systems. They see a combined 10% of the medicaid (leaving the other 40% with "coverage" but no PCP), average 20-25 patients per day, and leave every day by 5 pm. Patients regularly change to our clinic due to lack of access for their children when they are sick. The physicians in the other clinics routinely send patients to the ER at my hospital in order to avoid having to add inpatient responsibilities to their day. The hospital system has recently sent out contract renewals with...surprise!...10% salary reductions for those MDs.

My group has consistently refused to be bought out by our hospital. We abhor the idea that anyone but us make decisions on how to run our practice. This has resulted in overall benefits for our patients as we make changes based on how to best serve them, not what will be profitable for a hospital system. I cannot imagine working for a government paid salary. I would like to believe that I would continue to provide the same level of care I currently work hard to give, but over time, human nature would likely win.

And do we really need all those varieties of toilet paper. I get too confused with the choices. I think we could get by with regular and Congressional Strength Extra Wide roll. ('cause I think they produce more than we do.)

I do not think that having physicians on salary would solve the problem
Why not have the government bail us out and pay our student loans instead of bailing out the auto industry and the Banks.
Everyone seems to think that "Physicians" are just making the big bucks.
Very few of us if any give ourselves million dollar bonuses and fly on our own private jets.
We need to focus on congress and the senate so they can received the same coverage as the average "Joe"

The news media must be aware that Dr. Dean does not depend on his medical practice for his personal financial support, and possible never has. He needs to be in better touch with primary care and the current economic forces against it.

I'll take a salary, and work like everyone else on one w/ no incentive. I don't care how crowded we get, I'll just keep on pluggin' at a snail's pace. And when it comes time to make a real tough medical decision, I'll just refer to the administration as someone else will be determining what resources to use by then and I won't be paid enough to want to be an "expert."

I think we should ship Howard Dean off to Iraq. He will be more effective there.

without tort reform there is not a chance of this proposal coming together.I guess the trial lawyers will be salaried tooooo???

I have suggested many times: eliminate all middlemen--- government, HMO, medical insurance. They suck up huge percentages of the health care dollar without helping anyone in medical need. Go to strict doctor/patient relationship. Sliding scales; acceptance of deferred payment; acceptance of tiny payments--- perhaps even $5.00 per week--- for as long as it takes to pay the bill; occasional payment in kind; and--- oh my God!--- even some free care, such as: fix the frikking nursemaid's elbow in the waiting room; prescribe for the uncomplicated earache or toothache without charge; volunteer at a nursing home or a free clinic once a month; do house calls. Will we make less? Yes. Will we make far more than most workers in this country? Yes. Will we have much more credibility with our patients, and far more of their respect? Hell yes! And will WE have more self-respect? Most definitely--- except perhaps for those clowns who go to third world countries to give free medical care (and, wonder of wonders!, happen to get big, adulatory write-ups in the local papers) but refuse to see their own townsmen who are on Medicaid.

The scariest words you'll ever hear, " I'm from the government, and I'm here to help." Thomas Jefferson is actually seizing in his grave. Does anyone in our current government even understand what brought the Soviet Union to its knees? It's mind blowing that they can even say these things in the public press and not be taken immediately to the guillotine, or hung by piano wire from the nearest utility pole. The idea that Americans are expected to swallow this bullsh*&t hook, line and sinker, without so much as a whimper is unconscionable. It sounds pretty, and neat, and clean and it is wholeheartedly wrong. Look, all our healthcare problems will be solved if we would only stop paying those rich evil doctors soo much money. Then only the truly devoted would become physicians. The argument is already written against us. If we protest, well, then we don't really want reform, and we're the money grubbing bastards they always suspected we were, who shouldn't be taking care of patients to begin with. The American public loves the idea of a quick fix, especially if all they have to do is agree to pay physicians less. Politicians are hoping that Americans are too stupid to see beyond this smokescreen. The incredible waste, inefficiency, laziness, corruption and sheer lunacy that goes hand in hand with an enormous, centralized, government run health care system, or any system...Americans have no idea. However, I think they are getting a crash course in what happens when you have one. Oh, but maybe you could ask an old Soviet how they liked it. I say every physician in this country should go on strike, en masse, the day they pass this. I will see any patient for free, in my garage and do the best I can on that day to help them, but I will not show up at what will essentially be a government run institution where I am a lacky to shitty health care and corruption, that will ultimately kill more patients than it ever saves. He who holds the pursestrings has all of the power, and physicians would be forced to obey their master, regardless of whether or not it was the right thing to do for the patient. That is not the oath I took in medical school. Since when has any government been concerned with doing the right thing for any one human being? Governments do not concern themselves with doing the right thing, they concern themselves with doing whatever keeps them in power. They prey on societies worst fears and the quick fix is always, always, to shave off a little bit of freedom. "Just a wafer thin mint." Americans have some precious freedoms, but will they keep them?

As I understand it the "Public Option" payer mechanism does not necessitate physician salaries just as our current Medicare payer does not so require. If one wants to really get the insurance companies out of the payer mess, one should look to structuring a "Public Option" payer system that affirms the Dr-patient interaction / relationship, gets the middlemen, including lawyers, out of the health care trough, allows for physician groups to unite to negotiate reimbursement, allows for salaried physicians at VA's, CHC's, FQHC's and Public Health Clinics, allows for opt-out, has an EMR system that is financed by the government completely, and requires no malpractice premiums because of the creation of a government sponsored "no-fault" malpractice claims adjudication process.

BUT my guess is that physicians in general do not realize the opportunities that a "Public Option" allows. All many physicians see is "socialized medicine" and react instinctively to a "government takeover" of health care in the form of a "Public Option".

I suspect the first day after i go on salary, I will go on strike for better pay.
Now is the time for a "Doctors Union" not a cordial group, not an educational group, but a group ONLY interested in our interests and working on making our lives, however great, better.

What does putting physicians on a salary going to accomplish? Is it going to reduce the rising cost in health care? The answer is no. The problem is with the system. The current system rewards high cost health care. There is no incentive to practice good low cost health care. That would require them to pay us for taking a good history, doing a good physical and figuring out what is happening and reassuring the patient. Instead we have 15 minutes and we order a CT or an echo. There is also a disincentive if we're wrong. So to CYA, we order these expensive tests. I'm salaried and I don't get a bonus for every CT or echo I order but I also have no incentive to save money because the consequences is high. Fix the system or the cost will never come down.

They are targeting physicians because we don't have the lobbying power of the insurance industry, pharmaceutical companies, hospital groups, and American Bar Association.

Thanks Sermo for giving us the voice that AMA is not providing and misrepresenting.

Wow all these comments in just a few hours. Shows how strongly we feel about this!\

I have been an employed physician (hospital owned practice) my entire career. However, that is my choice and I would not want someone telling me that I have to be salaried.

I would love to be a federal employee and give up what I am doing now which is working 60-70 hour a week,on call three times a week and spend hours filling out meaningless forms. I would be working 37.5 hours per week with mandatory lunch breaks and continue to fill out meaningless forms and not have to take care of patients. If there is a patients who shows up I have learnt enough to be able to send him though the system to get him out of my office. I say this because I am coming close to my retirement and will advice all children to consider different vacation. I will move to a third world country to get my medical care where I will be able to pay for services that I need rather then what the government has planed for me.

WindWarrior puts it quite nicely. If we give up something, we should expect something in return.
As the Germans voted Hitler into power (legally), this may be our last chance to demand anyhing.
The notion of physians negotiating with the US Government is laughable. We have been demonized, and are now about to be enslaved, all for the greater good (which our Lords and Masters in Washington will define in keeping with their own enlightened self-interest).

What if we had professional baseball, basketball, football, hockey, and other players salaried? What if Oprah, Leno, Obermann were salaried, or actors or singers.... say what a general surgeon makes? (My pediatrician's salary would be too low).....

I think in primary care there needs to be some form of stipend as opposed to a salary. I am by no means a socialist . Several years ago the British Medical Journal looked at the primary care physician salary in the British National Health System and added in the office overhead stipend, the housing stipend, the educational stipend ( for the doctor, his staff and his children through university level, plus vacation and other benefits) and rightfully concluded that British PCPs earned more real dollars than a typical US primary care doc ( using MGMA figures). With only 2% of US medical students even considering primary care and with the average age of a PCP in my area at 63, there is going to be a severe workforce shortage soon unless reimbursement for cognitive services is improved dramatically.
I believe we could use a PCP guaranteed minimum in exchange for a certain level of work. That might include some loan forgiveness, overhead stipend and low interest equipment loans. I would hope that the bureaucrats would recognize that a geriatric practice will allow the doctor to see far fewer patients in a work day than a practice in the student housing section of a university town.
I would love to see PCPs get some relaxation of the Stark laws so they can join together and generate some passive income by putting together a lab to do the labwork they need ( If we have communicating EMR systems with everything " transparent and open" then overutilizers should be able to be identified easily and have to justify their ordering habits.) or simple diagnostic equipment that they dont have the volume to purchase or lease alone.
Straight salary sucks . Please excuse the French but Howard Dean always has been a f_cking as_hole and always will be.

Set my hours to 8-5 and I will accept a salary.

My salaried colleagues are for the most part very happy and NOT lazy. Seems to work for them, especially since they also get benefits, retirement, and other perks. They get to go to work every day and practice good medicine--then go home at night, be with their families, and not worry about declining reimbursements and arbitrary insurance contracts. I think being on salary could be a very viable national option, although maybe not for all (and certainly shouldn't be mandatory!!).

Put me on the same salary as senators , give me the same benefits ,vacations and percs and I'll sign on tomorrow. This will result in the same efficiency that we see in congress( but not improved health care).

These comments represent the neanderthal views of the very professionals responsible for this mess. Patient care has given way to venal interest in 90% of responses. Medical leadership is about the patients, not the doctors. Our money is assured when we are mindful of this. Wake up, relate to the miserable present, move on, and start championing our patients and what works for people in every western nation save ours.

No surprise. He's an idiot.

My own personalregret is that I have two children going into Medicine~ I feel badly that I did NOT advise them otherwise.....but they are going into it with the knowledge that the renumeration is not the issue - Medicine is still the Noblist of Professions.....

There are a number of Physicians who are anti-physician. I'm from NYS and we got rid of Antonio Novello, MD as the NYS Health Commissioner. But not before she ripped off the State of NY for over $40,000. I'll never forget Howard Dean's "I Have A Scream" Speech. Dr. Dean gave up medicine and patients (he's independently wealthy). He can speak for himself, but not for all American Doctors. If he likes salaried doctors he can go to Canada or the UK and wait in line for 6 months to get his health care. How can Medicine continue to get the best of the best, while all the doctors go on salary?

If I am salaried, then I am employed. Let someone else pay overhead, malpractice and benefits. An I will work 9 to 5 only.
As far as Gov. Dean: I would expect such comments from anyone who lives off the taxpayer's tit.

I agree with GGMANMD; If money is your primary incentive for working, then perhaps you are in the wrong field.

Healthcare reform is a funny thing. Is this really about access to care or the votes? By default, the people making decisions (politicians) are not affected by their decisions. They are guarenteed government healthcare and are only looking for re-election. Most are lawyers, so tort reform is out of the question. I believe that if they are for true reform, they should be first in line to accept the consequences of their decisions.

Among healthcare reform, I have heard no talk of multi-billion dollar insurance and drug company profits. t is impossible for Washington to be neutral in the debate as long as the excessive profits of drug and insurance companies are disseminated through the stock market and effect so many 401Ks (votes, campaign funds). Reigning in big business is painful and costs votes. Wall Street or Main Street...we know where America's politicians priorities lie. It is illegal to give a physician a pen with a drug name on it because it will change Rx habits, but ok to spend millions on <500 people in Washington. Expect the same logic with healthcare reform.

As a pulmonologist, prednisone is the only drug I prescribe that is less than $40/month to take. Free healthcare without free medications is a new car without an engine. My patients have no idea of the stresses by physicians. (80 hr work weeks, the time spent on the business of medicine/not patient care and the sacrifices dictacted by myself, my family and friends) How many people outside of medicine actually know what "call" is? Ask your patient's. Executive salaries, malpractice lawyers and drug companies feed off physicians efforts every day without the effort and dedication required for truly caring for the patient.

Physician reimbursement has been cut for years to control costs when executives pull 6 and 7 digit salaries. Truth of the matter: there are not enough physicians now to handle another 55 million patients. Cutting incentives to see patients wll only exacerbate this situation.

The harsh truth: We are a small portion of the "votes" in November. We will be the victims in this debate without a true voice.

Howard Dean is an idiot ......"nuff said!!! He should think before he opens his stupid mouth!!! He obviously has no idea what he is talking about!!!! Salaried physicians will for the most part be motivated to do the least amount of work possible to earn said given salary. Let me ask all of you... are you ready to be government employees??? I am not and I for one would seriously question whether I would continue as a doctor anymore. And if they don't address tort reform I am totally NOT on board with reform. Let's go back to HSA's for day to day stuff and use insurance the way it was originally intended for catastrophic medical issues only. Besides you wouldn't want to use your house insurance to pay for a broken window ..RIGHT???

This would result in the very long lines to get in to see physicians as they have in Canada. If I am on salary, I would definitely slow down and take my days much slower and easier than I currently do.

Something wicked this ways comes!!!. Change is needed but salaried physicians is not likely the answer. Granted in some setting it works, but not universally. We all know that despite salary, the same work load (and likely higher if we add another 10's of millions to the healthcare mix) and expectations will be demanded of us by the public and the government. They will never allow us to share the same benefits historically enjoyed by our future colleauges in the government or settings such as car manufacturers. We cannot unionize because it is against the law. We will have no say, UNLESS WE SPEAK UP NOW. Limiting healthcare at the primary care level will cause the American people to seek their answers in the ED's and urgent cares. They EXPECT their (non)emergency visits to be addressed quickly, courteously, professionally, and we in the ED's must provide MEET their expectations (not needs) so that the ED groups can stay in the good graces of the contract awarding hospitals so we can retain the contracts. The government is not perfect and needs perpetual attention, but never really gets "fixed", so why would we expect to fix healthcare. I think we should focus on OPTIMIZING healthcare..... it cannot (will not) be perfect, but it can be better. We need: tort reform, cost containment measures, better payment strategies, streamlined information sharing, better quality measures, re-educate patients on their expectations of the healthcare delivery machine, better dissemination to practitioners and patients of quality/outcomes research (so the patients expectations of their providers are balanced), and patient accountability for their healthcare. It is not presently, but should be a two-way street. I would be happy to work for $200/hour, with limited additional practice costs, and then time and a half for overtime and double/triple time for holidays, especially all the additional national holidays that i would either have off to spend with my family or make a better wage. So here are two (of 37) ways I can optimize healthcare: (1) FIX the banking system, I mean after all, since healthcare is causing such a problem for the government, lets fix the banking system and the stock market too, they caused and will continue to cause considerable stress to the government. Salary the banking and investment world, and put the profits toward paying for the greater good. My second recommendation is to stop wasting money on blood cultures in pneumonia and eliminate it as a quality measure, it rarely helps patient care and does not equate to quality care, and it costs CMS and private insurers more than its worth.

I'll do it when the ABA (lawyers) and investment bankers do it! When we save a life, we don't get a bonus percentage of their future value. The absurd arrogance or naivete of this "doctor" to suggest that we automatically become employed physicians. Then what will happen to the patient-physician relationship when decision making is removed from the exam room to the board room.

Salaried employees can join labor unions, stage legal job actions, etc. They may need to rethink that proposal.

I think there must be a great many people on this board who make w-a-a-y more than the average primary care doc. If you would admit it, I think that specialists making $500,000 a year for the same or less work than we do at under $200,000 are of course not going to want to be salaried. That would mean they have to actually accept a fair compensation instead of enjoying procedural privileges. It is by no means "slavery" to have a salary. Almost everyone who works for any kind of physician corporation--even their own--is being paid a salary plus a productivity incentive, excepting the national health service and the VA. Of course there would have to be a change in business models. Those who are so special that they simply can't work for anyone but themselves really ought to rethink their purpose in medicine--to take care of patients, to get rich, or to be able to boss everyone around?

Let's see:

1. Many physicians already have contracts where payment is not per salary. So Dean's presumed legislative solution may involve ex-post facto laws.
2. States and the federal government are not supposed to enact legislation impairing the obligation of contracts, so this would be another way in which Dean's suggestion may be unconstitutional.

I realize, of course, that only pedants, these days, worry about little things like whether a politician's recommendations are actually constitutional or not.

i have not read every comment about the proposed healthcare solution above but the majority of the ones i did seem to be focusing on what is good or bad(mostly bad) for the doctor. the primary focus of the debate - not just this issue of salaried doctors but whatever reform we decide on - should be what would be better OVERALL for the patient, all 300 million of us. the emphasis is on OVERALL. NO SYSTEM WILL BE PERFECT FOR EVERYBODY. we, as doctors, know best to put the good and bad together and come up w/ a solution. we do that everyday in our practice.

in my mind, after putting all the pluses and minuses, from the patient's point of view, salaried physicians is not a bad idea overall. it may reduce patient access,doctors may not have the incentive to go the extra mile for the patient but i can guarantee it will slow the rapid increase in healthcare costs, which we need to do in order to have universal coverage. whether we like to accept it or not, doctors do contribute to the cost of healthcare either by way of carelessness, or greed or ignorance. as a doctor i would like to concentrate on medical care and not on paperwork. one long term benefit of salaried physicians would be that only people with more of their focus on service than on money will go to the profession and we'll hear less of this griping.

will lawyers be on salary too? no mention of torts! pay me a nice salary and I will work like any other government employee-as little as possible-BUT only on the condition they cannot sue me and take my house and the savings set aside for my kids!

With 16 years of Privatepractice(fee for service)and 18 years of Federal mediicne (on a salary) my view is balanced. Both options are viable. YOUR priorities determine which realm is for you. If you have the skill to administer (or pay for it) fee for service is your bet. If youthink that patient care, research or teaching is your forte, a salaried position will prevail. The choice is yours-- forthe moment. The pendulum is swinging quickly to the salaried side. When that faIs, the free markaet will return,

There is something to be said for being paid for the care we give.(What a concept!) I haven't taken a salary from myself in over 5 years just to keep up with the overhead of taking care of my patients.Salaries for physicians are ok if they are reflective of the payment deserved for the care provided and are not paid out by another nonhealthcare profit grabbing industry but rather from the patients who are contracting for their care.What should be happening is a discussion regarding Catastrophic healthcare for all, which would considerably reduce costs to the system and applying the money left over to preventative care and taxdeductable Health care acoounts which the individual could use to contract their care for out patient primary care services. Then the primary care physicians would be paid for the care provided but should not be forced to pass this income onto employers since that would incentivise for once again increasing patient load at the expense of care. I would even go as far as to provide a set contracted yearly fee per person that would cover their physician care/time/consultation etc and limit the amount of patients per primary care physician so that proper time could be spent on the total care of the patient . This is as long as the contracted price is adequate to cover expenses overhead and salary compensatory with the professional service provided. This could easily and cheaply be provided from the HealhCare accounts or a separate fund from the Government for indigent or poorer patients. More people would then be incentivised to go into primary care and outpatient subspecialties because finally they would be paid properly and be allowed to practice without regulatory burden with greater time spent with their patient.

Realize that the argument for Salary is an attempt to divorce the Commodity aspect of Medical Care, viz, more encounters or procedures equals more money in your pocket. The inherent danger is when you get, sorry, VA or bureaucratic mentality of punching a clock rather than attempting to provide the most efficient and effective care.

Even the large groups or networks that work on salary still have bonus provisions. And, the salary may be based upon prior year's work (the RVU model that is so prevalent today.)

The key is the system in which one is working rather than the incentives. We focus on the peripheral markers rather than observing and measuring that which really matters. It's sort of like those surrogate markers for disease status - are you better off measuring CIMT, LDL-cholesterols as your marker, or CV morbidity and mortality? (In fairness, those particular difference are because of the differences in time frame for the sake of trying to be more "real time.")

And like the entire "medical home" or preventive issues - it depends upon what length of time one is speaking. For current insurers, they look at the length of the contract (with the employer) which is often renegotiated yearly to allow them to pass along the change in costs to them (i.e., you have an employee with increased costs, then the employer gets hit with higher fees; or they did poorly overall and need to increase the margin for profitability/Wall Street.)

One aspect is to ask or design a system that encourages preventive care/counseling and allows sufficient access to acute medical care. Then look at the best ways to compensate or encourage what is necessary and sufficient.

Make physicians TAX EXEMPT (like clergy); that would cover overhead cost rising, etc.
tax attorney malpractice fees 90%; lawyers will stop ambulance chasing
heavily tax alcohol and tobacco; allow med school loan interest to mean something at tax time. Just thinking out loud.

Obama wants to make us his slaves. How ironic is that?

If and when we all become actual employees of the federal government, instead of just having our livelihood remotely controlled by CMS and the profiteering insurance industry, will we recelve the same free health care that Congress gets? Will we be immune from liability like the government itself? Who will negotiate these issues for us? Smells like the old Soviet system to me.

Paging Dr. Obama: Time magazine cover title - US Chief Doctor

After watching the CNBC clip of Drs. Palestrant and Dean, I think the salient point is that our traditional CPT based reimbursement model, at least at the primary care level, doesn't work and, in fact, undermines quality of care. Whether the solution is salarying doctors depends entirely on how the salary is structured and what the expectations of the doctor are in return. For example, if a doctor were salaried to manage the health of a patient population or panel, and the salary were adjusted commensurate to how well he or she did in managing that population, it may not be such a bad thing. This would have to allow for the doctor to have some latitude in how that population was managed and would require some measurable outcomes.

I certainly don't advocate a flat salary without some type of performance incentive, but to get meaningful reform, we need to think creatively of ways to replace the CPT based piecemeal productivity based compensation model that we now practice in.

Also, regarding tort reform: IF we can reform the healthcare delivery model so that doctors and patients have a better relationship focused on shared expectations and outcomes, we shouldn't need tort reform. As quality from the patient's perspective improves, lawsuits will decrease.....problem solved.

As a surgeon, if salaried, what is my incentive to get up at 2AM to take care of someone with appendicitis? Why should I take care of the difficult cancer? Or that recurrent bowel obstruction in that patient who has undergone 5 previous surgeries? When I get the same amount of money to do only easy cases, why do hard cases? When the is no incentive to work harder, people stop working harder.

>>I certainly don't advocate a flat salary without some type of performance incentive, but to get meaningful reform, we need to think creatively of ways to replace the CPT based piecemeal productivity based compensation model that we now practice in. <<

Hows this for creative: Get the god damned government phased out of health care and return it to the free market so that we can once again has the best health care with the greatest abundance, affordability, charity, and progress in the world like we used to have.

Fine. I work about 12 hours a day on average. So here's what I want. I'm board certified in 2 specialties. I want 300.00 an hour and I won't even ask for paid vacation or ANY benefits. Let's see how that works out...ok so 50 weeks of work at 5 days on average is 250 days of work a year. 250 x 12 is 3000 hours a year. x 300.00 is 900,000.00 a year. FINE and DANDY. I'll take it. Pay me 900,000.00 a year Mr. MAN and I"ll see as many patients a day as I can possibly see. I'll keep my doors open for seeing patients at least 7 hours a day and won't charge you a dime more for the extra time I spend doing paper work. SHIT O'DEAR...hell ya....I'll take it. Before you folks get mad at me, understand that I am in private practice in Internal Medicine. I think last year working 8 hours a day, 4 days a week and doing hospice one day a week...Im also certified in Hospice and Palliative Medicine, going to 3 nursing homes, being the medical director for some wonderful mentally retarded folks(seriously) who live in group homes as part of state run program, taking care of my own hospital patients etc...i think I may grossed 300K. If you threw me a really good salary and allowed me to stay in PRIVATE PRACTICE>>AKA HELL, I'd possibly take it.

I do not feel that in of itself salaried physicians is a non starter. However it needs to be integrated into a larger reform plan. The reductionist approach of picking and choosing specific items from the world's health care models is shortsighted and ignorant of a greater whole. Reform which attempts to contain costs cannot be balanced solely on physcian reimbursement. Price controls on monopoly drugs and a national formulary with competitive bidding, tort reform with reduction in malpractice premiums and awards, rational limits on provision of expensive, technology intensive treatment in patients statistically unlikely to enjoy benefit (age,comorbidities, etc),discussion regarding the value of for profit insurance companies, reduction in the immense administrative burdens and costs along with the realignment of patient expectations in this new environment will be mandatory. In exchange I'd expect much improved work hours and relief of the burdens of running a small business. Given the expected minimal marginal gain by adding a patient I think a reduction in the competitive processes among private practice physicians would ensue. Fast, Cheap, and Good, ---pick 2. The demand from physicians can't be " you have to pay me " it has to be that the whole system requires reform with shared burdens and sacrifice among those that work in the system and not the irrational, corrupt, myopic reform that our government provides when big money influences taint the process.

Gov. Dean is clearly out of touch with the reality we live each and every day.

Yea, salary me too. Just pay me back what I spent on educating myself, pay all the overhead expenses, limit the number of patients I see, don't call me after 5 pm or before 8am or on my lunch hour, provide a pension and lifetime benefits for me and my family, and give me immunity from being sued. Patients can sue my employer.

Health Care Special Report: Paging Dr. Obama Aug. 10, 2009


Sermo Doc

Years ago as a medical student I shadowed the CEO of an HMO who said to me, "I can't seem to find the balance. If I pay the cardiologists a generous salary, they do 25% fewer procedures than expected for our practice and if I pay them by case, they do 25% more procedures than expected for our practice." The problem is that there is no quality or ethical control in the current medical system. To say that we should be salaried is insulting because it assumes that all doctors are capable and/or willing to provide the same kind of care, which we all know is not true. I think the system should remain private, but be subject to rigorous regulation from an ethical and quality standpoint so that patients are neither neglected nor unnecessarily overtreated.

And while were at it, lets put all the lawyers on salary. It is absurd to put all physicians on salary. I just opened private practice. If I assume all the risk, ie leases, salaries, insurance marketing, I am entitled to the profit. If the US gov payed our salaries, they would be making a profit from our services. There is no innovation or exceptional quality when the provider has the same outcome regardless of whether he or she actually cares/

PS :

Lets stop politicians from collecting fees for speeches after they retire and put them on a fixed income.

yeah, just to emphasize what has already been said many times.
1. if we're salaried, who will we work for? the government?
2. if we work for the government, won't they be calling the shots? isn't that "socialized" medicine?
3. agreed that in general, salary = don't work as hard for the same money (except that we're physicians and we work hard anyway). not necessarily opposed to people working on salary but see above.
4. howard dean is ... what can you say? this guy really has an m.d.?

I would be able to watch more of the playoffs though while at work

if you aint really sick, you can wait til the time outs

what?

As a resident looking to go into practice soon I am currently a "salaried" employee as all physicians once were. How would you like to go back to the residency model of practicing? I don't particularly care how many patients I see in clinic or in the hospital because it doesn't affect me with regards to performance and compensation. Also, if you're under salary you are an employee of whatever company or government is paying that salary and therefore subject to whatever terms they choose to set. So be prepared to see adjustments in your salary without your approval. Just ask any government employee now how much say the have in their salary. I don't have the answer but making all physicians salaried employees is not.

I would be happy to work for the government as long as it takes on my medical liability, all of my expenses, pays a salary appropriate to the level of training, allows for a 40 hour work week that includes the time necessary to keep up with the field(other industries get paid for such time), pays overtime for extra hours worked, allows doctors to organize and gives a government retirement on the taxpayers (just like other federal employees). No question, it would cut the costs of health care as the motivation to bust one's butt on a daily basis would decline and productivity would decline and there would be waiting lines for health care service. I can remember training at the VA where if a scheduled case might go past 15:00 it was cancelled and rescheduled. This may be the future of US healthcare cheap and no frills.

He who pays the piper calls the tune.

Personally, I prefer that be the patient, which is why I have no contracts with any third parties. It's also why I make crap money, but, there you have it.

reb3csc--I totally agree with everything you've said.

IF THERE IS NO MALPARACTICE; THE DOCTOR HAS NO EXPENSES OTHER THAN PERSONAL EXPENSES (like any other citizen); EITGH HOURS WORK DAY; 31 DAYS VACATIONS IN ADDITION TO THE HOLYDAYS; FREE EDUCATION; NO EMERGENCIES AND IF WE WANT TO FOLLOW THE RUSSIAN HEALTH CARE SYSTEM AS WELL AS ALL THE OTHER GOOD THINGS THAT GOES WITH THE ADMINISTRATION OF A COMMUNISTIC SOCIETY.....BY ALL MEANS, CONVERT THE USA INTO A DICTATORIAL STATE AND ELIMINATE VOTING BEACAUSE ALL THE ELETIONS, AT WHATEVER LEVEL, COST A LOT OF MONEY.

What a joke.
There are plenty of ways physicians who want to can work for a salary, e.g. VA, Kaiser, large clinics like Mayo, Lahey, etc., but in those situations the employer is responsible for all the overhead and your hours are set. In fact I can't think of any profession or job where an employee is responsible for overhead and payroll. I've heard if you take call at a VA, you get the next day off.
For those who don't want to be on a salary, they have the private practice option. Putting someone in practice on salary is impossible. What do you pay? How do you have overhead and expenses covered. Of course as those in private practice get squeezed further and further financially, this option is becoming less viable unless you opt out of accepting insurance, medicaid, medicare, etc.
Obviously Howard Dean is an idiot.

Thats why Im not a democrat!...What a fool

It would be completely immoral for them to force us to be government salaried employees and it would be DOUBLY immoral for us to accept this notion. Why? Because we have an oath that we are obligated to follow. That oath is based on moral principles. Not to mention, even if they started us on a killer salary, how long do you think it would be before that ratcheted it down to that of a public servant like a fireman or policeman? Anybody who thinks a physician should be a government salaried position (especially another physician) isn't thinking clearly (I was gonna say something else, but I decided to be nice).

All right Guys..Keep Pipe dreaming! We all need to do something outrageous so that we create a "teaching moment" over "beer" at White house. Right now, no one is listening! The politicians and lawyers have successfully cast doctors as a bunch of whining, greedy, rich spoiled Bastar&^%

There are so many issues with our current health system. I believe we should build from the ground up facilities built by the government, and staffed with government, salaried physicians. Specialties to be added soon after primary care. A similar structure to a large HMO but all meds/testing to be done and similar to Canada/English healthsystem. How would this work. Currently, we give a small amount of incentive to work in the VA and other government positions with loan repayment. You have to pay for quality. Consider substantial loan repayment(repaying a loan over 5-7 years regardless of loan amount). The government can possible write off the loans that we cannot and consider physician quality of life and yes, a salaried position would work. I believe this transition would work for those in private practice. Salaried positions work 40 hours a week and when physicians work more then that...without reimbursement ...disaster. When in private practive, you work longer, you reap the benefits.

Bodomo, there is no such think like ""free" education in this countries, you pay 2000$-3000$ a year for education plus books, etc, The salary of a specialist in Spain is 2500 euros/m.
Of course you pay your malpractice. You have the same paid if you take care of 1 or 600 patiens. Some number time for hip replacement 1 to 1,5 years, catarac 9 mto 1 years, heart surgery 3mo to 6 mo.
Why do you thing I am here?? I was a thoracic surgeon, and i did the all residency again, now I am a happy anesthesiolgy, If this #president# do this I will be doing somethik else

Make sure All lawyers also become salaried before they do that to Docs.

Are there any Democrats who have taken at least an introductory course in Economics? Their ideas and legislative activity says otherwise.

A $200,000 salary for a 40 hour work week??????
Where? Can I sign up now ?

I had worked on salary in the military for 15 years. I never saw a system where doing less for the patient was better. No malpractice issues therefore no concern for errors. No incentive to care for the patient. In private practice there is miuch more accountability. I would ask Howard Dean why he no longer is practicing medicine. The answer is most likely he does no want to work as hard as a real doctor of medicine does.

Howard Dean is a liberal moron. He has absolutely no clue as to what the practice of medicine involves today. He is a typical left leaning talking head with little experience with the true issues at hand. No other industry in a capitalistic society is subject to others telling them what their services/goods are worth and giving them a take or leave it offer. These people must be resisted with the most aggressive responses we have ever undertaken.

How do we define socialized medicine? By the very nature of the profession, medicine is "socialized". What we have now is the imposition of perverse financial incentives and the interposition of non-physician administrators in the process. We need a system that puts the physician-patient relationship first, and pays a fair salary to everyone involved.

There always has been, is, and will continue to be a 2 tier healthcare system in the good 'ol US of A!! If docs are forced to become salaried, it will be like we are all working at the VA or IHS or some other form of a state/county facility. But, not all doctors or patients are gonna except this. Patients with ways and means will not be forced into a VA/IHS/state/county program. Like me, they will seek out better, private healthcare and be willing to pay for it. And, there will be docs, like me, who will be glad to treat them on a fee for service basis. So everybody who opts in to the goverment's healthcare system will in essence become a VA/IHS/state/county program patient, and those who don't, will continue to receive better, private heathcare on a fee for service basis.
If you are forced into working for the government as a salaried doc at some VA/IHS/state/county facility, I would recommend that you immediately form an union in order to deal with the government employers. There is no insisting on the "right" to form an union, you just "do it:". If the government employers don't meet your demands, you go out on strike. If all, or most doctors in this great country participated in a strike, American medicine would come to a halt. Within days, weeks at most, the government would have to meet your demands, cuz there is no firing you to hire somebody else. Even if the government employers wanted to fire you and hire somebody else, it would take months to do so, because of all the "red tape" the government has already created in regulating docs.
As for me, I'm NOT gonna be a "government employee". I'll continue to see patients who can afford to pay me on a fee for service basis and I will continue to deliver to them the best healthcare their money can buy!!

I work for a salary with loads of incentives for harder work. My boss is no idiot as some are in Washington. I am making at the top end of my specialty, but I work my ass off. If there was a flat salary for seeing 10 patients vs the 40-50 I see a day well I will take the first option. Work my normal 60 hour work week forget it.

My guess: less physicians in medicine. No free enterprise = no incentive to work harder. Me personally, I'm going to leave medicine if the government is taking over my practice . I plan on opening a scuba instruction business with my husband, whose also a foot surgeon. Or maybe we wont work at all and collect welfare. PS Sucks to Obama. PSS Sucks to Obama's old physician in Chicago too who is advocating for a single payor system. Socialized medicine sucks too. phthth.

BRDOMPH- you are the shining exception to a very bad process and system. Read the many post by all of the many of those who have tried it and left.
More often than not, it does not work ( salaried postion) in the best interest of either the physician or the patient.

Dean s right, any body on this post from Mayo, Kaiser, Giesinger or maybe Bassett? Please chime in on this, I am sure you all live comfortably, I know I did when I was with a Kaiser subsidiary

Like most participating in this discussion, I work 12-14 hours many days of the week, and often return to the office on my days "off" to complete paperwork that was neglected while I was seeing patients. Doing otherwise would cause my practice to dwindle, as new referrals would be turned away and/or patients with complications would be left unseen and unhappy. If the government sets a flat salary for my efforts, there's no way I would continue to work in this manner. The end result would be less patient access to care, perhaps resulting in the need for another government-hired oncologist or two to pick up the extra work I wouldn't be doing. Is that a savings?

Also, government-controlled health care would mean than Uncle Sam (or at least Aunt Pelosi) would decide which locations need each form of specialty care, instead of private markets dictating the distribution. Under a socialized system, I would fully expect to have to relocate to a major urban area in order to continue to practice Hem/Onc, or face being "reassigned" to primary care otherwise.

I'm a salaried physician but I agree with amdcu93---being salaried may remove the incentive to work. Over the years, I've seen ingenious ways tried by some of my colleagues not to work while on salary. The abuse is something else. We've also tried to unionize but so far, I'm not sure it's been helpful. Perhaps, it's too early to tell and for a small group, we don't have a lot of clout...

Physicians should have a choice to be salaried or not.

i use to work at a community health center and was salaried. Some parts were great. Patients sought me out because I took time to explain things. But overhead expenses came into play, the big bosses began demanding a higher output. We stopped getting raises and cost of living adjustments and put on an incentive plan. I tried to see a lot of patients but patients began asking for another appointment if they saw one of my partners to see me, so I could explain things that they didn't understand at the previous visit with another partner. And more administrators were added to the payroll ( who pays their salary - we do, by billing patients), I became frustrated and left. went to work for another salaried office. Little did I know the parent entitiy was failing financially. We were bought out by a bigger agency, which didn't like some of the insurances our clinic had. Insurances were dropped, my patient load suffered and we took a financial hit. I was the only pediatrician in the group and became a liability so my whole office was closed. There were some benefits to being salaried but in this present environment, the only people able to make money ( bill for services) are physicians. who pays for all of the salaries of aall the bodies working in the office, we do. So you have to see a lot of patients to generate your salary plus the nurse, receptionist and the administrator. I decided to open my own office so that i could cut out some of the administrators. Now the only administrator telling me to see more patients is ME.

Daniel, you state that Howard Dean says he supports employee Dr model-but he adds "as long as thy are paid properly." Of course this leaves room for more discussion. ajaymd and others have similar ideas as mine: if we are salaried, we should be paid by the hour and have our time valued and chronic complex patients would get the benefit of more detailed interactions. I have this plan detailed on my blog: Sermo Doc

What Dr. Dean said about docs in UK is true: for less training they get paid more for primary care. My friend has less training than an equivalent PMD here, but makes 60 pounds/year and has no overhead. However, what he does not say is that while PMDs there make more, specialists do not.

I've seen other models too mentioned on blogs, yearly salary with bonuses etc...I personally think, as kevinh76 says, a salary with no bonuses for productivity can encourage laziness. True with hourly rates too. I've seen it. I like payment systems which have a base hourly rate with bonuses with those who are more productive. It provides security, quality, and also rewards those who see more.

As to what should the hourly rate be? I propose it should be at least the same hourly rate that insurance companies are willing to spend on attorneys to defend us doctors when we are sued.

I would like to see all legislators term limited!!!

If we as physicians are salaried then of course the antitrust limitations on us are no longer applicable. We can then unionize and collectively bargain for salary, hours, retirement and other benefits. I do not want to know unions but I believe that the overall feeling is that it does not lead to more efficient and caring work. The unions would LOVE to work with us! Is this really the model that that left wing wacko is suggesting. Remember, he was a physician only in name. He is of the left elite. A family with money .... remember Dean Witter, the financial giant. Another limousine liberal.

If we go on salary, the physician shortage will become readily apparent. It would lead to restricted healthcare based on availability. Some people will continue to work hard, but, like most government employees, most people will look to improve their lifestyle. This will indirectly lead to tremendous medical savings and may be the ultimate goal of his comment.
Ultimately, what the government wants is a single payer system with restricted access to procedures. Also, to create bigger government with greater control. They want to kill the free market and abolish capitolism. They can't stand to see individuals working hard and achieving success.

It has all been said eloquently. Incentive to work and compete in the free marketplace keeps the highest quality of persons pursuing medicine as a career. Hang up your stethoscope at 5PM and you dismiss the essential responsibilty for the care of your patients that is the crux of the profession.

It's insulting that the primary discussion in controlling health care costs centers on physician salaries. It is certainly not physician income that is driving the rising cost of healthcare. Physician salaries have been shrinking since I began medical school in 1991. Reimbursement continues to shrink.

Why does Dr. Dean not suggest salaried medical malpractice laywers from the government to address the nationwide malpractice crisis which is a large driver of cost?? Are they planning on capping attorney's fees?? I'm certain that would go over well with the democratic party and one of their largest contributors, the ABA. When do they begin addressing salaries for the insurance companies?? Blue cross, Aetna, etc salaried employees earn far higher salaries than the majority of physicians I know. Yes, overhead for running offices is high, abuse in the system is rampant, and overutilization is a major issue but the single biggest problem is the commoditization of what used to be considered a noble profession.

Latinomd- Thanks for the compliment. The ONLY reason I get compensated well is my employer is a real doctor. He doesn't mind his people making good money if they work hard and take good care of the patients.
Overall the idea of a straight salary will likely be a disaster. My boss will fire those that abuse the salary system he has constructed.
I have like some tried the private practice thing and discovered I truly and completely SUCK as at business. This job is a good fit for me, not all, but me.

Lewin Group Clarification on review of HR 3200:

Clarifica...pdf (92.0 KB)

Lewin Group Claification:
Technical Points of Clarification on The Lewin Group's Analysis of
the American Affordable Health Choices Act of 2009
This document addresses several technical questions regarding the estimates in the
recent Lewin Group report, "Analysis of the July 15 draft of The American Affordable
Health Choices Act of 2009" prepared for The Heritage Foundation.1
In our paper, we estimate that the public plan will provide insurance products that are
less costly than private insurance. This is achieved by paying providers up to 32 percent
less for services than private insurers must pay (assuming Medicare reimbursement
levels plus five percent), and by eliminating the allowance for profits and insurance
agent and broker and agent commissions found in private health plan premiums. As a
consequence, we estimate that many employers and consumers would experience
savings.
For example, we show that the public plan would reduce family premiums resulting in
average annual savings of $2,148 for families and $1,104 for individuals. Consequently,
we project that many employers and individuals would shift to the exchange and the
public plan to take advantage of these savings. We estimate that a total of 103.4 million
people would enroll in the public plan when it is opened to all individuals and
employers.
A key difference between the Lewin and CBO estimates is that we assume that the
newly established "Commissioner" would exercise his or her authority to extend
eligibility for the exchange to all employers in the third year of the program, while the
CBO does not.
There are six points raised in the Stark critique that we respond to here.
1. Enrollment: The CBO predicts 12 million people in the public plan compared with the
Lewin estimate of 103.4 million people.
Response:
As explained above, we estimate that the public plan will save more than CBO
assumed. The CBO also assumes that eligibility for the public plan is never
extended beyond firms with fewer than 20 workers, while we assume the
Commissioner would exercise his/her authority to extend eligibility to all
employers so that all can take advantage of the projected premium savings.
1 Communication of July 20,2009 from Congressman Pete Stark, Chairman of the House Ways
and Means Health Subcommittee, on the Lewin Group's analysis of H.R. 3200.

Continue Lewin Report :

2. The CBO estimates an increase in employer-sponsored insurance of 2.0 million people
while we estimate that 88 million workers and dependents enroll in the public plan.
Response:
In Figure 4 of our paper, we show that the number of people with coverage
sponsored by employers increases by 1.4 million people. The difference is that
we estimate that about 88 million people would be in firms that decide to
purchase coverage for their workers in the exchange and then elect the public
plan option.
3. Lewin assumes that providers would participate in the public plan regardless of what it
pays.
Response:
We assume that provider participation in the public plan would be similar to
participation under Medicare, where the same payment levels are used (In fact
payments in the public plan for physicians will often be Medicare plus five
percent). We also assumed that providers would not be subject to the same
utilization management controls that are used by private plans. The cost of the
resulting increase utilization of health services in the public plan is reflected in
our public plan premiums and discussed in Appendix A of our paper.
4. Lewin estimates that premium savings in the public plan will be lower than CBO
assumes, because private insurers will step up their cost containment efforts.
Response:
The assumption that private insurers could close the premium gap with
enhanced cost containment is unrealistic in the context of how insurers control
costs.
a. Insurer bargaining leverage is diminished under the program. Insurers
typically negotiate "volume" discounts with providers. Thus the more people
a plan covers the more bargaining leverage it has in obtaining these
discounts. Because millions of people move to the private plan, insurer
bargaining leverage is diminished.
b. Consolidations across hospitals and physician groups have eliminated
provider competition in some areas, thus reducing the plan's ability to
leverage discounts. For example, a plan has little leverage in negotiating
discounts if there are no other hospital systems in the area

I have worked both for salary and fee for service as an emergency physician. I was salaried under a highly respected university medical system, and I am currently under a progressive, physician run emergency group.

Hands down, fee for service increases efficiency and produces happier doctors. This, in turn, leads to happier patients. The quality of care is equally good under both systems, just more efficient under fee for service.

Lewin continued :

c. The effectiveness of provider networks is diminished by the program. Key to
the effectiveness of networks is the plan's ability to channel patients to the
providers who are participating in the plan's cost containment efforts.
However, provider network formation is experienced by patients as
restrictions on access. Increased reliance on these approaches would further
alienate patients resulting in a greater shift to the public plan.
d. Intensification of insurer utilization management practices would also further
alienate patients and providers.
5. Experience with FEHBP and other programs show that price is not the only factor in
choosing a health plan.
Response:
This is basically true, although in the FEHBP experience, the coverage provided
differs across each plan offered. There are differences in co-insurance, covered
services and network availability etc. This differs from the exchange model
where people pick among competing plans with virtually the same co-pays and
coverage. This will increase the relative importance of price and quality
indicators in selecting a plan.
Also, as discussed in Appendix A of our paper, we do account for differences in
price response by age and health status, which controls for some of these issues
raised by the critique. For example, we account for the fact that when faced with
a lower cost coverage option, older and sicker individuals are less likely to
change coverage than are younger and healthier people.
6. Lewin assumes that the Commissioner exercises his/her option to extend public plan
eligibility to all employers.
Response:
At this time, the only thing in the House bill that results in savings for workers is
the public plan. If the Commissioner does not extend eligibility to all, most
people would see no cost containment. In our next study, we show the impacts
with and without extending eligibility to firms with over 20 workers.

I only want to take care of healthy people who speak English and that all lawsuits will be paid by Mr. Obama.

Lewin Continue:

c. The effectiveness of provider networks is diminished by the program. Key to
the effectiveness of networks is the plan's ability to channel patients to the
providers who are participating in the plan's cost containment efforts.
However, provider network formation is experienced by patients as
restrictions on access. Increased reliance on these approaches would further
alienate patients resulting in a greater shift to the public plan.
d. Intensification of insurer utilization management practices would also further
alienate patients and providers.
5. Experience with FEHBP and other programs show that price is not the only factor in
choosing a health plan.
Response:
This is basically true, although in the FEHBP experience, the coverage provided
differs across each plan offered. There are differences in co-insurance, covered
services and network availability etc. This differs from the exchange model
where people pick among competing plans with virtually the same co-pays and
coverage. This will increase the relative importance of price and quality
indicators in selecting a plan.
Also, as discussed in Appendix A of our paper, we do account for differences in
price response by age and health status, which controls for some of these issues
raised by the critique. For example, we account for the fact that when faced with
a lower cost coverage option, older and sicker individuals are less likely to
change coverage than are younger and healthier people.
6. Lewin assumes that the Commissioner exercises his/her option to extend public plan
eligibility to all employers.
Response:
At this time, the only thing in the House bill that results in savings for workers is
the public plan. If the Commissioner does not extend eligibility to all, most
people would see no cost containment. In our next study, we show the impacts
with and without extending eligibility to firms with over 20 workers.

I agree with docLMG because i am a Pediatrician and our costs seem to skyrocket when you least expect it!

I have been working as salaried psychiatrist for 3 years now, with a salary that I NEGOTIATED at a place that I CHOSE. If we were to become employees of the government we would have to take what they gave us or not be able to work. If the government were to decide how much I would get paid and where I had to work I would seriously consider going back to being a CPA.

Howard Dean & his minions are as stupid as rocks (not to insult rocks). What planet do they live on? (Screams into a pillow)

Who is going to run my part-time solo psychiatric practice? Who's going to pay mt rent/malpractice/office insurance/phone bills/business loan/office supplies/furnishings etc. A solo psych practice is probably the cheapest of all practices to run and my over-head was running about $2500/mo until I finished paying my start-up business loan & moved to a cheaper office. That was with no staff. There were some months I just worked to pay my overhead.

Is the government going to take over every practice? HAHAHAHAHA

Exactly how would I get a salary? Who is going to pay the overhead for my friend the family doc who just opened his own practice - opting to make less $ and spend more time with patients anyway? Who's going to pay my $50K med school bills? Is med school going to be free? Mine was about the cheapest med school in the country (UNC-CH) but living expenses don't go away. I went on the "go into debt as you go" plan! That was living in a mobile home too.

And most of all - who's going to decide what my salary is going to be? Right now, govt reinbursement for most psychiatric services have been steadily declining since I went into practice 10 yrs ago;worked private practice and as an in-pt doc at a community hospital. No one was paying me a salary; we all had to bill individually. (Taking a break to scream into a pillow some more}

I left the hospital after 3 years. Couldn't make enough $ to cover the time I spent with the pts (we worked it out - came to about $30/hour). Couldn't pay my overhead with that. I opted out of all insurance 5 yrs ago; I see patients for an hourly fee - some sliding scale & a few pro-bono. I'm lucky; my husband's salary and parents living with me supplement my meager income!

My husband, who works for a company that is seeing the patients the state mental health system used to take care of, makes a salary. As a child psychiatrist he could make a lot more in private practice but he wants to take care of the neediest and sickest. However, he has to earn not only his salary in reimbursements but also enough to contribute to the overhead.(as are all the physicians in the physician-run company). The states are opting OUT of mental health care because they just "can't afford it" - so WTF? is the federal govt going to do??

Hubby often sees 12-18 pts a day. He's booked out 6 weeks. Works 10 hour days mostly. Has to run to keep in place with the no show medicaid/medicare pts and meager ins. co. payments. Who's going to account for the $ practices lose due to pts not showing up?

If he's "on a salary", who pays the overhead? You better believe he wouldn't be seeing 14 people. Most of the academics I know are now forced to earn their salaries in patient reimbursements. I don't know any psych practices where docs "salaries" who don't also have to contribute to the overhead.

Even though there is "socialized medicine" in the UK & Canada, all physicians are not required to participate. Of course, people have to be able to afford them. My parents got sick visiting the UK . They got the service of a UK concierge Dr who also saw pts for US visiting pts for their travel insurance company. He came to their hotel room to treat them. How's that for a haves/have nots gap?

Excuse me now. I have to go back to screaming in the pillow. And doing the paperwork required to close my practice.

Several of the comments above bewilder me in stating that "indigents deserve care, too," and "Everyone deserves needed health care." When I was a medical student at L.A. county hospital, 1/3rd of all admissions were heroin related. The drug of choice has changed, but the principle remains. Suppose a heroin addict sticks his gun in your face and takes your wallet. Does he deserve it? Of course he does not. If he then takes your money to buy heroin, injects contaminated junk cut with talc and kills his kidneys, he then immediately is entitled to dialysis, is covered by medicare, may apply for full disability benefits, and is now entitled not only to your wallet, he may even sign your childrens' names to an IOU to China for as much health care as he can spend. I have never seen a man too poor to buy his alcohol. Is he "entitled" to top-tier health care and access to a trial lawyer if it is not up to his satisfaction? I am a Plastic, Reconstructive, Hand surgeon on call at least every third day and night for the past 21 years of solo practice, having provided care for every imaginable injury. For the most part it is a true statement that most people with jaw fractures deserve them. No one "deserves" the services and assets of another without creating slavery. Each year since 1988 I have given away between $100,000 and $160,000 in uncompensated indigent care, so please do not sling the prejudicial assumption that I sit in my Medi-spa doing only lipos and botox. I do what I do because it is my personal obligation to my profession, to my community, and to God. Any system so absolutely contrary to natural law which would not only reward bad personal behavior but create slaves of those who would help the self-destructive individual will inevitably fail. If I must work for the government for a salary to practice medicine I will move abroad or farm wheat. Good luck finding three guys to do the work I presently do.

They pretend to pay us, we pretend to work... Who else is going to take care of my patients? Who is going to do my surgeries? Cystoscopies? Ureteroscopies? PAs? NPs? Chiropractors? Insurance execs? Politicians? God help us and our patients!

If I am salaried, then who will be my boss? Who do I get to complain to about my lousy work environment? Who is going to pay my employees? Who will hire and fire my employees? If I get sued, does that mean my boss gets sued too due to vicarious liablility? Assuming that paying me a salary saves money, that means I make less money...so why should care about quality at all? Does he think I will be anything more than a triage center if I am salaried? Howard Dean.....you have not thought about this enough.

...a few points:
1. I commend Dan for his courage & intelligence, & for contributing in bringing this opportunity about, ie., to be in the media as OUR voice......because as I see it, we've
NOT had a voice up until now. Personally, I think you were effective, proactive and quick on your feet.
2. I am a salaried MD in my full-time position; I started out in a successful private practice that became increasingly unpleasant due to a continued dip in the quality of my life, (& that of my family) in dealing with the pressures of overhead exacerbated by problems with getting paid by the various insurers. (But I enjoyed being a physician to my patients, and a colleague to my peers; so, it still was difficult to make the change.) I feel that I chose the lesser of the two evils. As a salaried physician, I work hard and , more often than not, put in a significant amount of extra time for which I receive nothing; it's my belief that no matter what the personal setting, that most of my colleagues ( probably not including Dr Dean) feel that they are not commensurately compensated for what they do &/or what they have to endure. The suggestion that MD's be salaried exclusively is ridiculous, but more transparently, DECEPTIVE & DEFLECTIVE. It distracts from the real issues at hand, Tort Reform being one of the biggies, and its progeny, Defensive Medicine...(& that's not to mention the Pharmaceuticals). We should be fairly recompensed, no matter whether it be a salaried position or private practice. It's not the setting....it's the word 'FAIR' that is key.
3. I would appeal to my colleagues that to be a viable force, we need to be kind to one another, and that criitiques should be constructive. We have enough to worry about from without, so we should not damage ourselves from within. Let's not be 'autoimmune'.
4. In my opinion, no party represents us. The Donkeys are for the lawyers, and the Elephants are for insurers....all the more why we need to be together and be genuinely for the patient, & for a healthcare system that's healthy. It continues to amaze me how a bunch of nonmedical people can exclude us and come up with these plans that are really skirting the main issues. Wrong diagnosis, wrong treatment.
Whatever....thanks for listening. Good day to everybody.

To be salaried means that one is employed by someone else. Employment means there is a mutual agreement between employer and employee on the services to be provided for pay received. It is completely voluntary. I'm in an employed situation right now. However, if I am forced to work for someone else on their terms alone that is not employment. That is slavery.

If the government would like to employ me then I would be happy to discuss the service expectations and the pay I would expect in return. But if the government wants to tell me I HAVE to work for them for pay decided only by the government then my answer would have to be "no." I believe slavery was abolished many decades ago.

Gov. Dean's comment is absurd. The fact that he said this in a public forum tells us the DNC is completely out of touch with the state of medicine. The fact that there has not been an immediate, high profile response to his comment from medicine is very ominous. Physician reimbursement has been declining for decades, and many are now struggling. Social subsidies for the poor and elderly were well intended, but have been subverted for other purposes. The government , press, and insurance companies have all cast physicians as money grubbing parasites responsible for every increase in health care costs, and have posed themselves and the public as victims. They never talk about the soaring cost of overhead, malpractice insurance, compliance/regulatory issues, and the billions of dollars wasted on IT (which in my hospital has displaced God). They have been so effective at brainwashing the public that unless you have direct involvement in medicine and know better, you believe their rhetoric. Physicians are hamstrung by their inability to have a strong voice, and the AMA has certainly not helped things. We have all worked too hard and long to be forced into government servitude. We must find a way to communicate the dire state of the profession before all our dedicated colleguges depart, and we are left with a group of "pyhsician extenders" to care for us. We're getting change all right. I hope that the America I love (and it's medical system) will be here for my children. The diagnosis for Gov. Dean is cerebral constipation.

There are many ways to work for salaries, but the model Howard Dean is talking about is the government employee 40 hour a week model. There is no way physicians will be as productive when they are on a fixed salary. There will be no incentive to work more than the minimum. It happens all the time.

Put me on salary and my office will open at 9am and close at 4pm with 1.5 hours for lunch. I can kick back and see only 8 patients per day. No incentive to do anything more.

It would be just like the post-office.

I think making physicians accept a salary is a socialistic idea. Combining this with a public option will only decrease access to providers as many of them will opt out of seeing patients from the public system. Finally, many people will lose their current insurance as companies stop providing health insurance as the public system will be cheaper. This will ultimately leave a larger group of people with less care.

I would work on salary.......and would stop work each day at 8 hrs., no more and no less. I would then have someone to work nights and weekends take over. In the end, the hospital and the fed government would find out what a bargain they had when they paid ONE surgeon 300 dollars a case to do the work of 3 salaried surgeons. When they figure out that it will cost them 750-900K to replace me they will wonder why they ever screwed with the system. And don't even talk about continuity or quality of care. Just try to find me after hours.....you'll get the most polite voice mail you've ever heard....just like when I try to call the government.

For those among us who say their fellow doctors are 'greedy' and 'selfish':

Do YOU work for free? Would you do your current job for $30,000/year? Or even $75,000/year?

Yeah, I thought not. Like it or not, THERE'S NOTHING WRONG with money being part of the the physician equation! It's only a matter of DEGREE.

In other words, an intelligent physician--who could make a million bucks a year as a lawyer--needs to make SOME kind of decent living, better than most, in order to:

a) reward them for their hard post-college work to become a physician (TEN years for me!)

b) encourage others to join the profession

c) keep people from turning to more lucrative professions

See, it's a package deal! Altruism, honor, compensation, respect, intellectual stimulation--they're ALL a part of what gives a physician satisfaction.

Seems like the govt is going to take more than a couple of those away from us, with money being only the most obvious and easily quantifiable.

Some of you need to get off your high horses and face this reality: physicians DESERVE to make a better living than most people (there, I said it!)

I can't think of another profession that requires as much intelligence, sacrifice, and start-up money (med school and business); another profession that creates stress on such a personal level (worrying for my patients, worrying for my family); another profession that helps people so much yet so often asks for so little (just show up for your appts, take your medicine, follow my instructions--and stop cursing at my nurse on the phone!)

Do we deserve a million bucks a year? No, not quite. But most of us darn well deserve to be paid well into the six-figures (heck, average lawyer compensation in my area is OVER 500K/year!). Let's not be ashamed of that, please.

I believe the power of a united front by Union or similar type of organization and the right to strike or similar action could force the govement to treat physician farirer and give the Physicians more power which they don't have now. Only with full power can we get better care for our patients with less paper work and limit the powers of non physicans in health care a drug costs E.J.Brotman M.D.

Under the present healthcare system I have no recourse when private and profit making insurance companies deny me payment for work I have done. Even worse, they refuse payment to hospitals, labs, diagnostic radiology and physicians, breaking the financial back of my patients or endangering their lives when I say they need admission that they refuse to pay for. Preventive medicine for the uninsured is a joke in the USA. They can not afford to come in for physical and health counseling. With the government in charge, I, and all health care providers and patients can protest at the ballot box or in the streets. Try that with United Health or Aetna. Peter Bogdan MD

A salaried position in medicine would be ok by me if:
every other position in various industries like insurance, financial services, sports, executive management, etc. were also subject to similar terms. The conditions should include bonus repayment for my investment in educational expenses, four to six weeks paid vacation time annually, limits on my workday and workweek, and bonuses for productivity. Government paid malpractice, disability, and life insurance. Personal and sick days. Oh, and the right to unionize and salary arbitration.

Under those conditions, I would listen to the offer. Wonder what Bambam, the buttboy for Wall St. and financial services, would say to those provisions? Do I hear the crooks at Goldman Sacks screaming?

I'm tired of this crap. If we get the shaft in this deal (if....????), then we need to walk out and shut the system down until Bambam and his cronies are on their knees begging. We've been responsible citizens for a long, long time. Now it's time to play hardball and grow a pair.

I have a private practice. Will whoever is going to pay my salary also be paying the salary of my employees ? ...by the way, they want a raise.

I'm assuming that the government would pay my salary with a negotiated amount with all the details agreed on by my union and the HHS. Of course, overhead and liability insurance premiums would have to be paid also. Under those circumstances, I would be happy to practice. I would be out of the 'business' of medicine, which I hate, and just do my job.

To cut health care costs, have the insurance companies do there job; Pay the claims at a reasonable and fair rate. Not control care by pre-autherizations and restrictions, there job is to pay the bill and my job is to do what is best for my patient.. Change the tort and mal practice system which adds significant cost to health care. Finally follow the old axium " government hands off" !!!!!!!!!!!!!!!!!

timeoff296

For those who think that being salaried means they'll be able to see few patients, think again. First, they would have to buy every practice. The government would impose no limit in the number of patients to be seen on a daily basis because:
1)there won't be enough physicians anyway to see the hordes of patients wanting to use their government run health care. If you refuse to see patients, uncle Sam will come and get your license.
2)is an excellent way of reducing cost, same salary despite number of patients,
3)government will drive private insurance carriers out of business and at the end either you work for the government or you get out and raise sheep.
4)on the eyes of the government, doctors are the souless, arrogant, profiteers of human sufering that just make too much money. They need to be punished.
But more terrifying is that without being salaried their health care reform could still lower significantly reimbursement rates making it more difficult to survive in a struggling private practice. Thousands of jobs will be lost under "single payer" health care system, when private insurers go belly up, and the country will still be drowning in debt for generations to come, and yet, they haven't even fixed Medicare/Medicaid.
Somebody please put those idiots on their pills again!!!!

I agree with RKA0822's comments. I worked in the military for 25 years and although the level of compensation did not match the private sector it was based on experience, specialty, and potentially on effort. Malpractice was covered and no overhead expenses to be concerned about. The care in the the military is high quality due to the providers and the concern for the patients. There is the potential for reducing "incentive" with a salaried system but it totally depends on the individual provider. On the other hand, a salaried system would reduce the number of hours that physicians work and the impact on access to care would be enormous. The reduction in resident work hours was an important change for the safety of patients and the physicians themselves but the impact on healthcare was also tremendous.
I am a firm believer in capitalism but if you compare the US healthcare system to most of the other industrialized nations in the world the difference is not in the provision of care but in the administrative costs. Our office deals with 8 - 20 different payors each month and although the electronic submission process is standardized there are still a number of differences between payors and each of those payors has an administrative staff to pay. Patients need a choice - a total single provider system won't work - but
some simplification of the system and reduction in insurance costs is essential.

A BETTER IDEA:

Pay CONGRESS they way Medicare pays US. NO salary!

In order to be paid, your legislative representatives must CODE each and every professional activity, RECORD the content of that activity as specified by hundreds of possible bullet points and SUBMIT the activity code with a CHARGE code that must MATCH they activity according to a predetermined set of criteria.

They must then WAIT for the reimbursement for their work according to a SET FEE SCHEDULE that decreases every year in the name of budget neutrality.

NO charges can be submitted for conferences, education, professional development, administrative activities, phone calls, extra time spent, handholding, meeting with lobbyists, confering with collegues or writing letters. No extra fees for after-hours activities. Only FACE-TO-FACE activities are to be paid. Many activities must be BUNDLED into one charge even though there is value attached to combining activities into fewer encounters.

They must then SUBMIT to audits by for-profit contractors paid a bounty for finding noncompliance generated by mandated standards that are impossible to achieve in real life. If violations are found they must expect to REFUND prior revenue based on a small sample of activity, pay a FINE, get EJECTED from Congress and even go to JAIL.

Would health care reform look different if these were the rules in Congress?

Fredpedshemonc
Those MDs advocating salaried positions are overlooking an important fact.--Presently they can negotiate their salaries because they have the option of private practice. What's going to happen when the only employer is THE GOVERNMENT. Think you'll get a raise? duh!

I was called up for the Gulf War and was sent to San Diego for a year. I was on salary. it was great. Clinic opened at 8:00 closed at 4:30. On call two weeks, off for six. But when I was on call I had house staff to lighten the burden Nights and weekends were phone call. I offered to come in, and was told not to (it would have set a bad precedent). Plenty of free time. The phone didn't ring at night.
Thirty days of leave. Pay was based on year of my commission, specialty training, etc. My housing was reimbursed 100% tax free. I got $35 a day for food (also tax free).
The patients were great. Phenomenal pathology. People wanting to get better and not looking for drugs, disability, or suing someone.

I loved it.

BUT the productivity was nowhere what occurs in the private sector. It was strictly an eight hour day, five days a week. I became a star player with the house staff because some of the physicians would play the lazy game. ("This consult can wait." or "It's not a spinal tap headache. She doesn't need a blood patch." or "This MRI can be done in two weeks.")


Physicians in private practice have to work almost thirty hours a week just to cover their fixed costs. The real income doesn't start until then. If we go to a salaried system the lines will stretch as far as you can see.

Get gown in the trenches and ask the docs where the money is wasted.

Lets get rid of the drug seekers that are on medicaid and medicare. WE (taxpayers) are already paying for their office visits even if they do not get drugs...not to mention their drugs if they do get them...and xrays for complaints of nonexistent injuries. Then we pay for law enforcement and DEA officials and drug related crime...Yesterday I saw three who were on medicaid/medicare and they had xrays and such...it is a daily thing. If you do the math that could add up to a trillion dollars at least. Drug test everyone on these programs randomly and kick them off if they do not pass or if they are caught in falsifying complaints to get drugs. Taking apap/hydrocodone off the market is looking better everyday.

Then they come after doctors for medicare fraud? What about the patients?

At least if we work for the govt we get all the holidays off!

Another great government program! What a joke.

Sermo Doc

I think there are two issues:

I think there are two issues. First, while dr Palestano has done a wonderful job with this site, he has no significant experience in paractice so has a limited experience base for his arguments. That puts him in a tough position to spar with a seasoned politician like Dean. Secondly, the real queston is who is going to pay and how much. Most physician employment models that have used salary have also seen maerked decrease in productivity. Further, if I am not doing well financially doing what I am doing with the associated stresses, I will do something else. I don't think a mass exodus of doctors from medicine will be much of a reform.

Pay my school loans(49 years old and still got 'em),give me a livable wage,pay my overhead and get me out of the office at 5pm? Let me practice at a pace and quality I can accept and I'm sooo in! Also,frankly I just think we have to do something radically different and soon. We have been doing the same thing for many years expecting different results...insane,no? Most of the folks in Washington who would have us keep the system wholly "privatized" also wanted to privatize Social Security(allowed investing it in the stock market).Not sure that would have worked out well.

Being salaried would lead to lesser hours of wodrk and pdrob. less testing BUT the sicker pts would have much less care than neede.

If I have to work for the goverment and go "all in" and use card check with my colleagues and form a labor union. If were going socialist, might as well join the system. It would appear labor unions get favored status, so there you go...

Military medicine on a better salary. The whole crux is, what would the salary be? Most of us work very hard and see as many patients as we can. So, if the government wants to pay me more than I make now and cancel private ins., fine with me. I always have been a dreamer.

I have no problem having physicians on a salary as long as the salary were fair reimbursement for my services. Unfortunately, I fear that "Joe the Plumber's hourly" would be far greater than mine!

I have no problem having physicians on a salary as long as the salary were fair reimbursement for my services. Unfortunately, I fear that "Joe the Plumber's hourly" would be far greater than mine!

I have no problem having physicians on a salary as long as the salary were fair reimbursement for my services. Unfortunately, I fear that "Joe the Plumber's hourly" would be far greater than mine!

I have no problem having physicians on a salary as long as the salary were fair reimbursement for my services. Unfortunately, I fear that "Joe the Plumber's hourly" would be far greater than mine!

If you make us all salaried you take away our incentive to work. You get paid the same whether you see 1 patient a day or 30 patients a day. Look at Canada...my friends there can't get a doctors appt for months...and for some specialists years. Is that an improvement in medical care? Look at everything else the government gets involved in....FUBAR!
If the government wants to salary all physicians they are going to have to go out and find some that are willing to be hired. I would bet that most of us are not!! Good luck!

I thought my grandfather came to America, the land of opportunity. I wonder sometime however, comrades, if he never left Russia. I want to be free to have my own business. I dont want the people who brougt me the War in Vietnam, the lack of WMD iin Iraq, the 10 trillion dollar deficts, etc, etc, etc, to determine what is best for me, my family and my patients. Perhaps everyone in the country does not have the same ability, the same drive, and the same work ethic. Perhaps it should not be a crime to work hard and make some money. It is nice to be paid chump change to make life and death decisions in a situation where failure is not an option and give over 50% of the money back. I guess I'll see you in the gulag.

If you want to understand how a salary based system works, look no further than the VA hospital system. It takes months to be seen by a physician, and the wait for surgery is excessive. Some hospital do not offer all services, and they do not pay for a patient to get a procedure at a different facility. It does not work at the VA, why would it work elsewhere?

I fully agree with the comment that access and care will suffer. If I am going to earn the same amount for seeing 10 patients a day as seeing 30, then why would i even consider seeing more than 10.

It is clear that those who have never worked for a living, should not be telling those of us who are productive how to practice medicine. Hmmmm, sounds strangely like the AMA leadership!

If the gov't wants to pay me say $50,000 per year to care for a % of uninsured patients, I would probably take it. Right now I get nothing. These uninsured patients cannot sue for malpractice.

I left a good job and went back to college then medical school then an additional four years of internship and residency training. I did this comfortable with the knowledge that I would still be able to make a good and appropriate living when I got back out in the real world. During those years in school and training I was not putting money into retirement, investing or acquiring material goods. You add to that the money I barrowed to attend medical school plus the years of "salary" I am out during training and by the time I start practicing I am in a deep financial hole when compared to my peers who did not choose to spend an addition 8+ years learning and training to practice their craft. I do not want to be rich. I just want to be able to live comfortably, provide for my family and someday retire.

People have no problem paying to buy cars, big televisions, expensive clothes, expensive homes and paying to repair those items. But, they are unwilling and unhappy to spend any money on their bodies and their health. There is a perception that this is a god given right and should somehow be provided gratis. People need to eat and need clothes on their backs and shoes on their feet. I don't see the government telling the grocery chains or JC Penney that they need to cut costs every year and provide for everyone.

People don't begrudge the veterinarian, electrician, lawyer, plumber, banker or business owner success. If you work hard and do good work you should be appropriately rewarded. People regard these people as brilliant, successful and deserving. Physicians are somehow viewed differently. There are few profesions that require as much training, vigilence, concentration, sacrifice and pure time.

If you try to salary me you had better make certain that I am appropriately compensated or I, like many others, will leave medicine. It will be difficult to attract the best and the brightest to the profession. The future of medicine in this country will without doubt be in question.

I am at the point after 11 years in practice that I would almost welcome being salaried. They can have the overhead, the ridiculous cost of vaccines, and the malpractice. My salay is already limited by the fact that I don't "do" enough to patients. Overhead is increasing and these insurance companies deny more. Primary care as a business model FAILS MISERABLY. However, after $100,000 to get an education, the choice to be salaried should remain MINE. This is still a democracy is it not?

I agree with a lot of the ideas mentioned here. Salaried physicians = socialized medicine = reduced access. There is no incentive to see more if you get paid the same; this is the model of the Federal Government (VA, military, etc.) and it has problems. If we are salaried, we should be allowed to unionize. If we are salaried, then the government should pick up overhead costs, labor costs for support personnel, and malpractice costs. I'm glad Dr. Palestrant went head to head with Howard . . . his and our message needed to be heard!

DrBarks is right! A massive strike with 50% taking off and 50% remaining to only coveri emergencies. Maybe the patients will realize what we contribute. Everyone seems to assume the salary we would be paid would be better than what we make now (working 12 hours and seeing 30/day). I am assuming the ObamaRation plan expects to "save" money by cutting our pay. Its the only way they have figured out so far to cut Medicare spending besides their fraud patrol which is basically blackmail. So why think that we will be working for decent salaries with expectations of seeing fewer patients. They will replace primary care with nurse practitioners and PAs. We need to have a HUGE national day of protest with all of us out there in our white jackets clamoring. And we should not be embarassed that we want to be paid. When I have patients asking why I don't call back individual normal test results, I tell them I would NEVER get home if I did that. The Oprah and Survivor watching crowd has no idea what 12 hour days, call, or even the amount of studying required to get thru medical school is about. And it appears Howard Dean has forgotten.

I was on salary in academia and then on salary from a health care system for a number of years. I am part time because I love to practice medicine, but did not think it was reasonable to try to raise millions of dollars to open a pathology lab, and then not be able to make reasonable business decisions because the market is so artificially controlled. That would be putting my family in an unjustifiably risky situation, Just imagine if we were all free ( as we are supposed to be in this country), free of government micromanagement, free of insurance company interference, free of harrassment of frivolous lawsuits. We could indeed provide low cost quality care. The CEO where I work is not a physician, and the administrators and board of directors are not, either (by design). the turnover rate of physicians is very high. There are a lot of locums docs. In my opinion, it is a darn shame for all of us patients that the local life-long family doc is being forced into extinction. From a patient safety perspective, it is a disaster. I see so much fragmented care, by design in our current beaurocratically micromanaged health care system. Soon, docs will be replaced by robots with a flow chart, and then we will see bigger problems. When a doc took care of patients and families for many years, he go to know what was normal FOR THAT PERSON. Every doc knows that some symptoms may be insignificant in one person but a sign of serious life-threatening condition in another. But, the personal art of medicine is not considered by those who are gradually, steadily, forcing us into complete slavery. Why are docs only (in some circumstances) not permitted to own hospitals, offer doctor-designed and admninstered health insurance options, TALK to each other about costs? Us poor patients are not allowed to know the costs of medical consultations, if an insurance company is in the mix. I sympathize with those of you who have expressed frustration in not being able to live as a free man in our chosen profession of medicine. I, too, have had to look elsewhere to live the American dream of participating fully in the free enter prise system (which is why I only work part time in medicine). In talking with other docs, it seems to me that those who work in a practice that they own, or one that is owned or operated by physicians are happy and that the others are treated as just another piece of machinery, and of limited value.
It seems to me that we are living in the Atlas Shrugged novel. If you have not read it yet, I recommend it. In this case we docs are singled out because we are easy to push around, and because we devoted all our lives to science and medicine (thus no time to develop the "street smarts" that the enslavers use), and are generally good-hearted and possibly find it hard to believe that other people are not.

Ridiculous. Really, salaried by the government.... really? Howard you're a fool. Find yourself a socialist home elsewhere and leave our country.

I saw what happened when I went from private practice to academia, i.e. salaried.
Some guys had two half days to see patients and each one of the 5 patients they saw got at least 30-60 minutes. Who cares about giving good care or attracting patients if you get same salary no matter what you do? The system was too big and complicated to see what any one doc was doing.

Just as soon as all lawyers and politicians are salaried.

I f I want to give 10% for free, I should be able to choose to whom I give free services. Medicare calls it fraud if we don't collect the copays. I don't want someone dictating that I HAVE to see a certain percentage for free. I have noticed that those who have to pay NO copay are the most abusive and demanding. If any doctor wants to donate 90% for free or 0% for free, fine with me. I don't want a bureaucrat telling me what I HAVE to donate and to whom.

If doctors are salaried, so should other professionals...lawyers, business owners, accountants, etc. We would then work 9-5 jobs watching the clock for those last 30 minutes. I would have more time with my family and friends, which would be nice, but I am sure that ultimately the profession would lose the noble position it now has and patient care would suffer. The one good point would be lower total cost of health care.

I will be happy with a salary when I get to work like most in congress. I get to show up a few times a week, get summer and Christmas "recess" whether or not the work is done up to that point, decide what kind of topics (or patients) I will agree to work on today, have my retirement plan set up without self contributions, have a wonderful, no-deductable health plan for myself and my family, be able to accept a pen from a drug company or medical equipment manufacturer --- oh, and be able to vote myself a raise.

Sign me up!!

We do not need to preach to the choir anymore. We need physician leadership and a seat at the table of any healthcare issues. The AMA is not doing it so who will fill the gap?
It is time physicians formed an active group that truly represents the interests of both physicians and patients and not middle men. Enough talk...we are missing the boat . It is time to stand up for our profession and our patients.

I have worked in private practice and am now a hospital employee.. I also spent 4 years in the Air Force as a government employee. No way did I work the hours, either in the Air Force or now as an employee, that I put in while in private practice (self employed). Put us all on salary and there is going to be an immediate reduction in access for patients.

What the government giveth, the government taketh away. After years of getting no increases in pay, the British Columbia Medical Association finally negotiated with the BC government to be included in the government employees retirement package. The ankle is in even dry on the contract and the government reneged on the deal. How can you negotiate with or sue a single payor when it is your ONLY possible employer? In addition, I have seen few models of physician practice that work without some sort of incentive bonuses.

We need to submit a bill that would:
1. Keep the basic fee for service of the present system
2. Provide government catastrophic coverage over $250K
3. Provide government coverage for those who show up in the ER without coverage
4. Eliminate absurd executive salaries in health care and for that matter in every publicly traded corporation. Perhaps return profits to the insured.
If everyone is salaried, very few will work hard and access will be poor and we will have the waiting line of the Canadian system.

Everyone should read The New Yorker article by Atul Gawande "The Cost Conundrum". The article made very poignant points about where medicine might go nationally (if not already heading that way). The article discusses a town in Texas that has double the national average for Medicare expenditure while not really delivering anything more than average health care. The Mayo model discussed in the article is essentially a "salaried" model that seems to work. It spends less than the national average while delivering excellent care. However one who works for the Mayo accepts a "salaried position". I imagine the disparity in salaries of internists to sub-specialists is not as disparate in the Mayo model (but I have no proof of that as I write this). But something in the Mayo model seems to work better from the way it is presented in this article.

As an internist, we generally have no "procedures" to generate revenue. The only procedure for most internists/PCP's is the actual visits themselves and perhaps vaccines. The reality is we don't have real procedures that we over-utilize, except perhaps for "too frequent or ineffective office visits". The reality is that most of us are too busy taking on too many new patients that need PCP's (in the setting of a shortage of PCP's) that we don't make patients come back too soon. Vaccines are generally a good "procedure" and do help prevent disease. The only real abuse might be PCP's that see too many patients in a day and deliver lesser quality care as they rush through their day. Fortunately most PCP's have not been tainted by the entrepreneurial nature of medicine because they have not been given the opportunities that "proceduralists" have been given.

Bottom line -
1) We need to cost contain our country's health care. Countries that have PCP driven health systems are probably more cost-effective and deliver better health care than we do.

2) Given human nature, most sub-specialists will provide their "bread and butter procedure" more often than is probably indicated medically (such as a cardiac cath for cardiologists or a stent to go with it; or such as a laminectomy for a neurosurgeon; or such as a scope for a gastroenterologist; etc, etc.). Whether this occurs because of sub-specialty biases or malpractice fears or whether it occurs because of conscious or sub-conscious financial personal gain, it does not matter. Simply stated - it is happening and seems to be getting worse. This needs to be reined in to control our escalating health care costs.

3) PCP's should be salaried or paid at a much higher pay than present (minimum of $250K) to really make medical students want to go into primary care over the next 10 years to help rein in the escalating health care costs. It is money well spent by the government to pay PCP's better to attract them into the field that will help rein in the much more costly aspects of healthcare.

4) We have a huge PCP shortage that is only about to get worse when we insure the 40 million people that are presently un-insured. Giving them insurance will cost us more than we can imagine. Most of these newly insured patients will take that insurance and use it by going to ER's and walk-ins as there are simply not enough PCP's to take care of them (it happened already in Mass when they insured the un-insured). This does not even take into account the increasing number of Medicare baby boomers that are coming of age of medical need over the next many years.

4) The collaborative model that allows specialists to perform tests when indicated medically and not when they make more money is much better for the patient and the cost of healthcare. This is where the Mayo model maybe succeeding and the rest of the country is not.

5) Lastly is a disclosure- I do not work for the Mayo but it does look like an attractive model to consider.

Any comments on my thoughts?

Thanks

I so agree that Physicians should be Salaied with$200,000.
I have been practicing for 35 years and has all the INCENTIVES OF QUALITY CARE TO ALL MY PATIENTS. THAT THEY LOVE TO BE FOLLOWED IN MY OFFICE . I have more consultations in my Specialty on referrals . BUT IF THE GOV'T WILL MAKE ALL PHYSICIANS SALARIED THE QUALITY OF CARE AND NUMBERS OF DOCTORS WILL BE DEPLETED AS TIME GOES ON BY 2020. THEY WILL BE NO MORE INCENTIVES . THEN ALL PHYSICIANS WILL JUST WORK FOR 8 HOURS AND WILL OR MIGHT DO OTHER EXTRA WORK FOR ANOTHER BUSINESS TO MAKE THINGS WORK FOR THEIR FAMILIES.
SALARIED PHYSICIANS IS MORE THAN SOCIALISTIC MEDICINE AND SO THAT WE WILL ALL EMBRACE NOTHING MORE THAN SOCIALISTIC GOVERNMENT.
WHAT AND WHERE IS THE ENTHUASIASTIC INCENTIVES TO SPECIALTY AND primary care be. These all will down the drain. DOCTOR OF MEDICINE TAKE AT LEAST 12 TO 15 YEARS OF STUDY AND TRAINING. THESE DOES NOT COMENSURATE FOR THE LONG STUDY KNOWLEDGE AND TRAINING OF BEING A DOCTOR OF MEDICINE. THE GOVERNOR OF VERMONT IS PLAIN STUPID BEING A DOCTOR . THAT WHY HE RUN FOR GOVERNOR INSTEAD OF BEING A DOCTOR TO PRACTICE. HE HAD NO EXPERIENCE OF MEDICINE PRACTICE AND ENTHUSIASTIC CARE OF THE PATIENT. HE WILL MAKE THE PRESIDENCY IF HE RUNS.
HOPING IN THE HOPE THAT OUR ORCHESTRATED CAMPAIGN BY ALL PHYSICIANS AND SURGEION WILL FOCUS ON OUR LOCAL CONGRESSMAN AND SENATOR WITH A UNITED LETTER PROVIDED BY SERMO IN DIFFERENT FORMAT TO MAKE IT INVITING TO THE CONGRESSIONAL COMPAIGN. I HOPE THE THE CONGRESS AND SENATOR SHOULD NOT IGNORE THE DOCTORS QUALITY AND DEDICATED CARE IN OUR COUNTRY . THE GOV'T OFFICIALS ONE OF THIS DAY WILL NEED A SPECIAL CARE TO THEIR RESPECTIVE FAMILY ONE DAY IN THEIR LIFE. LET US MAKE SURE THAT THIS IS THE LAST, LAST , LAST AND FOR MOST LAST REFORM FOR THE BENEFIT OF THE PHYSICIANS AND THE QUALITY CARE TO ALL CITIZEN OF THE UNITED STATES.
THANK YOU,
ALEX P. YADAO,MD
BDBEST

If all medical education debt is erased and medical education is free...then I would consider it. If medical education is not in the equation of this massive change then forget it. Folks who are trying to make these rules dont take all the factors into consideration. Great Howard Dean who seems to have a lot of verbal clout. Sure I would take the salary but only if it is level with that of a malpractice lawyer!

The difference between the salaried nurses and the hourly nurses at my wife's ECF is that the salaried nurses get stuck on understaffed shifts until somebody shows up to relieve them(sometimes after 20 hours!) with management telling them that if they leave they are abandoning their patients under threat to their licensure. The hourly nurses can get stuck too, but at least it's at time&1/2.
Why would it be any different for a salaried doc? Fixed uncome with unlimited time obligations. I was a 12 year old snow shoveler when I learned, you always charge by the job, never by the hour or under contract for infinite jobs. The most important capitalistic lesson I ever got, at the cost of a sore back. No thanks, Dr.(and I use the term loosely) Dean.

The fact is that I don't think anyone realizes the amount of non-pay time docs spend due to the pressures of paper-work and committee crap, and if we go to a salaried situation, people are going to be absolutely shocked at what the -REAL- shortfall of physicians is in this country, if they're all working 40 hour weeks.

The "salary" issue is an attempt by Dr Dean to blame doctors for the cost of care. He learned the Obamic lesson of blaming someone else for their own failures.

Tort reform and changing incentives for all the components of the health care system, including employers, employees, insurances and responsible medical associations is what is needed. Tort reform and incentive changes can be done without destroying what we have now...not a perfect system, but one of the best in the world. Government intervention can only result in trading quality for cost, mediocre everything and everyone and further transition to a socialized un-american life style.

WTOSCHES-

You forgot to mention the most important group of professionals of all who need to start the ball rolling by setting the example......THE LIARS.....I mean, THE LAWYERS!!!

But of course, I forgot folks like Howard Dean are already salaried...silly me, but then, again he's only in the position he's in as a politician because of his intense need and desire to serve the public.....of course, he's not interested in the money aspect of the job.

I guess, when he hangs up politics he'll return to his former life as a stock boy in the 7-11 that was just around the corner from the tenement he, his mother, and his 11 siblings actually use as their dwelling spot,

But of course, thank Allah for EMTALA which will guarantee at the very least that he and his family can at least count on emergency care since there would be no way any private doctor could render service unless this bill passes and they were salaried.

Families USA, a hot lobbying group well connected to the Obama admin., has stated in the past that their target income for physicians is 80,000/year.

Families USA, a hot lobbying group well connected to the Obama admin., has stated in the past that their target income for physicians is 80,000/year.

Iam tired of spending a good part of my day figuering out whether this patient can have this or will it be covered. I already pay an LPN 18$/hr. to get overrides and diagnostics covered for my patients.If they cover my overhead and clear the path to get care for my patients. Salary will be something to look at, just as long as in the trenches doctors are making the rules . We have had enough of the "goverment types" making the health care system unbarerable for everyone already.
By the way Mr Obama were did you get the idea that docs make money by odering test?
Come spend a day with me, it cost me money to get them passed the insurance companies. Never mind vaccinating the children covered by private insurance.Last time I looked I am as still eating my staffs time and the supplies to administer them. They have gotten so expensive I can afford to have them on stock all the time. So since I participate in the VFC program so my self pay and Medicaid patients get vaccines at their visits. But I have to send the ones the parents carry private insurance for ,to the health dept because I can not get fully reiumbursed for some vaccines like varivax or can not afford to keep several thousand dollars worth sitting in my fridge. Now that's the kicker.
Obama is worried about physcians making money on diagnostics ,but no worry on Insurance CEOs making MILLIONS, but children covered under their insurance plans having to wait until their doctors can afford to get vaccines or go to health departments for vaccines. I have patients that just go there and get no well care then we have 2 -3 year olds that have developmental issues that are being missed. Because parents do not have the time or care to make two stops to get well care and vaccinations .

Dean's commentary reminds me of a famous quote by a former tennis star,

"You can't be serious. You CANNOT be SERIOUS!"

It should be a choice-That will also will give choice to patients-they can go to govt clinics or go to private clinics.They already have a system in place-military hospitals,public health service,VA and federal civil service.In these settings doctors who choose to work there are paid salaries ,with vacation,and retirement benefits.Of course one has to put up with lot of crap.

right on, ajaymd, I agree c that !

It seems tort reform has completely fallen of the map. It's the one item that would get physician acceptance toward a more encompassing plan. It looks like it has already been lobbied out of the discussion by the ABA.

I think most of what the Obama administration and Democrats are currently proposing is a ruse to make us ultimately happy to take what we would have thought not long ago to be a really bad deal. I.e., by the time they're done, we'll be ecstatic to take only an 8% cut in reimbursement.

rothmd40 Int. Med. During my Air Force tenure i practiced with 11 other General Medical Physicians; we had a large outpt. base and 2 of us saw 40% of outpt. visits. No salary differential! One internist actually loaded his schedule with "hunting and fishing" buddies then took every afternoon off to join them in his favorite pastime.You take the incentive out of any profession and you'll have a "Classic Government Employee"!Thanx Howard, i'm nearly 70 and ready to accept my old comrades philosophy: " i'll only givum what they pay me"

Wow!!!. there is no more room for comment. Looks like every inch of "it"has been dissected. I am now working for an HMO group on salary for the past 5 yrs. I am getting out of it because for several reasons: 1. Work is hard. Your schedule is q 10 mins. between patients. 2. Patient impaneled to you is as many as 4-5000 thousand. 3, No control of the schedule. 4. Bosses who run the office are nurses who tells you what to do. 5. Bonus structure is hard to meet to get a decent bonus at the end of the quarter. 6. Because of too many patients impaneled to you very hard to keep up their lab. results, x-ray results and too many prescriptions and phone calls to fill and return end of the day. Your task is never ending no matter how many hours you put in a day. 7. With that long hours I put in , I think I could make more money by being an independent hospitalist with low over head as some of my friends are doing and they do not have a boss. Being an employee, you lose your independence. You will never see the money that the CEO is making who runs the Corporation.

There is already a government run plan with salaried physicians in place. It's called Tri-care and I worked in that system for ten years. In general, the primary care physicians were overworked and it was very difficult to get specialists to see patients. As a resident in the system I remember one week in cardiology when the physician I was assigned to saw 4 or less patients a day. Many referrals were rejected as "can be handled at the primary care level." Now that I have been in civilian practice for two years I can say that in general patients get more attentive care and have more access to care in a work for your money environment. It would be interesting to know the financial details of the tricare system.

After 3 years of private practice, I took up a salaried job. During my years in private practice, I learnt that unnecessary surgery is rampant. While I looked for indicated knee arthroscopies, other surgeons routinely scoped 4 to 6 knees per week. No surprise there - knee scope pays extremely well for 30 minute OR time. People scoped arthritic knees. People scoped knees with meniscal tear without trying any conservative management on basis of MRI alone.

So I do think that salaries doctors have a role in health care. We as a profession have abused the system by paying attention to billing and not the patient. I am in favor of Kaiser like system which is a MD owned insurance and careprovider company. There is no incentive to do unnecessary surgeries and run up health care bill.

Unless we recognize as a profession the abuse of system done by many in our ranks - society will dictate our lives. That is coming..

I am a salaried employee and have been voicing for a change for over a year now. It is plain and simple, there is no incentive to work harder. Period. ( ....I don't think I could work much harder..but that's not the point! ). If things change to a VA type of system, their would be docs clocking out at 5 oclock stepping over the pt's body in the lobby who have have coded.......it's true because I know it goes on now!

i would like a "stipend", not a salary, for seeing, say 5 patients a day, at $80 each per visit. If they need blood tests, i will send them to the closest, cheapest lab and the gov't can agree topay for that. I could accept that. I would still have my own place and my own practice to run as i see fit. AND OF COURSE, I will only accept those patients i want to accept. No patient