White Coat Underground

The state of Michigan is facing massive budget cuts which will further eviscerate the Medicaid program. If the legislature passes it’s budget as planned, massive cuts to Medicaid will reduce federal matching funds further limiting access to health care for the state’s many uninsured. It’s not clear if there is a way out of this, other than a massive overhaul of the nation’s health care system.

But lawmakers are looking for termporizing measures. One of these is to levy a tax on doctors. This is insane.

Medicaid pays pennies on the dollar so many physicians (my practice included) cannot afford to participate. This means that our already narrow-margin business would be assessed an additional 4% tax on our gross receipts (in addition to income and small business taxes).

There is already a shortage of primary care physicians, and if health care reform passes, more people will have insurance and seek our care. If we tax doctors to provide care, we are shooting ourselves in the neck.

This is not simply a self-preservation issue for me—the abject stupidity of a narrowly-applied tax for a societal benefit is odd, and to apply it to the people trying to provide the service is even crazier. Providers who already take care of Medicaid patients will still pay the tax, but may see a rise in compensation (although I doubt that it will make it profitable to care for these patients).

If this goes through, may practices are going to be in trouble. In addition to cutting our own pay, we will probably have to implement draconian measures such as dropping health care for our employees and probably laying off at least one worker (out of five).

This is a monumentally stupid idea. If you live in Michigan or in any other state where there are such proposals, make some noise.

Comments

#1 Toaster
September 30, 2009

Time for a roadtrip to Lansing, apparently. Get several MDs to storm the Michigan Legislature and check members for signs of dementia, ought to be sobering for them.
#2 micheleinmichigan
September 30, 2009

Well, being in Michigan, I did send a message to my rep and senator. I said I didn’t want the cuts to Medicaid or Community Health. I did not want the assessment on Physicians.

To be honest, I felt somewhat uncertain about the assessment on Physicians. Many who are employed by companies have lost benefits and had salary cuts in the last couple of years (I am talking about my husband, I’m self-employed). The more the merrier. (that’s supposed to be dark humor)

But on balance it seems to me that the amount of money that could be raised in such an assessment could be more easily tolerated when spread across the general population and it should be the general population’s responsibility to pay for their fellow citizens in need.

I don’t have much hope about a great result, things seem pretty bleak.
#3 David
September 30, 2009

Underpayment was a big factor in my decision to leave practice. My clinic population was poor, disabled, and mostly either uninsured or medicare/medicaid. There’s already a tax, at close to 100%, on physicians who care for these patients, in the form of not getting paid. And as you point out…

Medicaid pays pennies on the dollar so many physicians (my practice included) cannot afford to participate.

So, despite the evils of private insurance, my position remains that a single-payor system would be like medicare: chronically underfunded, manipulated by politicians, and ultimately bankrupting to physicians.
#4 dean
September 30, 2009

Yes, it is monumentally stupid, as are the proposed cuts in education and other areas.

Equally monumentally stupid are the state legislators who took last weekend to spend a weekend on Mackinac Island rather than staying in Lansing to work on the problem.

Of course, the fact that the whole bunch of them has let the problem go this long without any serious work is the most monumentally stupid (and galling) point of all.
#5 PalMD
September 30, 2009

A few hours ago, I contacted my representative. Her aide said that she was still considering the proposal. I wrote this letter:

Dear Representative Barnett,

My name is {PalMD} and I am a primary care physician in {your district}.

I have a small medical practice, with three doctors and five other employees, some of whom are your constituents. If 5386 passes and we are taxed an additional 4%, we will probably, in addition to cutting our own pay, have to get rid of employee health benefits and lay off at least one employee. We are a very narrow margin business.

Does it seem like a good idea to levy an additional tax on the people providing the services we are trying to save? It’s hard enough to attract primary care doctors. Four percent of medical grads are going into primary care, and in the program that I teach in we’ve only had one or two in the last few years. I can’t find anyone sane who would take a job like mine, given the hours, the pay, and the hassle (thankfully, I love it).

Please, convince your colleagues of the idiocy of this bill. I have never voted for a republican in my life, despite the fact that demographics say I “should”, but if it’s the only way to save my business, I’ll have to consider it.

Sincerely,{PalMD}

I just received the following response:

Dear {PalMD},

Thank you for contacting me to express your opposition to the QAAP tax currently being considered by the state legislature. I appreciate your thoughts on this matter and share many of your concerns.

After reviewing this issue thoroughly, speaking with many medical professionals and getting feedback from a wide range of constituents I have decided that I can not support this proposal at this time.

While those in support argue that a QAAP tax would benefit physicians by allowing for higher Medicaid reimbursements, I believe that we need real, across the board and comprehensive tax reform to revitalize our state’s economy, and this special tax on doctors would be a step in the wrong direction.

I greatly appreciate you taking the time to share your thoughts and experience as we work through this difficult process. I welcome any additional information you wish to share and hope you will contact me if you have other questions or concerns.

Vicki Barnett

State Representative
#6 makarios
September 30, 2009

In response to your post I just contacted my representative’s office. I was assured that she would oppose this bill. I think we should all urge others to do the same. It really makes a difference.
#7 micheleinmichigan
September 30, 2009

I’m not one of those committed to the single payer idea, but I would like to point out that it might differ from medicare in that the voters might be more willing to fund their own benefits than someone elses. It’s alot more attractive to underfund something that you yourself aren’t relying on.

Of course SP’s not in any current legislation, so the point is mote. At this point I’m just hoping we get some kind of health reform, even the pre-existing condition requirement would help alot of people.
#8 Colin
September 30, 2009

Good job MI legislature, I now have no interest in applying to your med schools nor practicing there afterward if you are this removed from reality.

Sorry PalMD.
#9 PalMD
September 30, 2009

It hasn’t passed yet!
#10 Colin
September 30, 2009

Very true, takes only a few nuts to make something so asinine.
#11 Donna B.
September 30, 2009

This type of measure is exactly why I DO NOT support health care reform in any way that it is/has been written/suggested.

I’ve not yet seen any plan where Primary Care Physicians will not be the first to have their pay (and authority) cut and where specialty clinics, such as those who treat my husband’s cancers, will not be put out of of business.

I abhor competition between (among?) specialists. Today I had a long conversation with the equivalent of an insurance nurse who, along with me, wondered whether I needed a consult with a neurologist or a neurosurgeon. The insurance person worried about who should order an MRI and I simply want an MRI done. After the radiologist report, I could more easily choose between the two specialists.

If the tumor has grown, or there are additional tumors, a neurosurgeon is, without doubt, the optimal track. However, if the tumor is the same or smaller, a referral to a neurologist might be the best course of action.

There are also new symptoms since the last MRI to take into consideration — tremor in both hands, right knee and left hip “failure” as in they are simply not there when I need them, but they do not hurt, and the ever present headaches and visual “disturbances”. Also there are the exquisitely painful muscle spasms in my legs that elicit moans and screams from me… childbirth is nothing compared to these, thankfully infrequent, pains. Unfortunately they last 2 to 3 hours.

I feel like I do not need health insurance reform — what better insurance can one have than Tricare? What I need and want is health CARE reform.

I do want a “medical home” where a Primary Care Physician might look at a complete, thorough blood assay and find that I might be anemic, I might have a hypothyroid disorder, perhaps I need B12 injections… or that all my blood work is normal and I must learn to live with the deficits of having a brain tumor, or have it surgically removed.

And… much more. I haven’t even touched the gastro and hernia problems from the bariatric surgery I had years ago.

I am being referred back to the same neurologist who said he had nothing to offer me 18 mos ago. The only change is the tremors and increasing frequency of other symptoms.

I no longer bother telling doctors that I am have constant pain in my shoulders, neck, upper and lower back, wrists, and hands.

Because of my bariatric surgery and subsequent hernias and GERD, I don’t take any anti-inflammatory drugs. Before I had any of these procedures or problems, I learned that ibuprofen caused my blood pressure to rise and swelling in my hands and feet.

For pain, Tylenol is essentially all that is available to me, although I have methocarbomal to take as needed. The problem is that I don’t know when a muscle relaxer or a pain reliever is needed. And I’m not sure the muscle relaxer doesn’t have the same side effects that NSAIDs do.

So, even though my chances of getting an appointment with a Primary Care Physician are next to nil, I certainly don’t want to see you guys taxed out of even that small chance I might have to see you.
#12 Neuro-conservative
October 1, 2009

Given your support for the public option, the monumental hypocrisy of your post is truly breathtaking.
#13 daedalus2u
October 1, 2009

These kinds of draconian methods would likely cause substantial animosity toward members of government, their staff, and families by physicians. Some physicians (all?) might be so upset they would be forced to recuse themselves from treating any member of government, their staff and families for non-emergency medical care.
#14 Jennifer Ronan
February 11, 2010

I saw on the news that Granholm is putting a Doctors tax in the proposed budget for next year. Amazing, she just doesn’t get it. But this is from a woman years back stated that doctors should see Medicaid patients for free. I think that we may need to continue to stay in touch with our Representatives regarding this matter.