Althouse: "I calculated that every time I have a Medicare patient it’s like handing them a $20 bill when they leave."

५ एप्रिल, २००८

"I calculated that every time I have a Medicare patient it’s like handing them a $20 bill when they leave."

"I never went into medicine to get rich, but I never expected to feel as disrespected as I feel. Where is the incentive for a practice like ours?"

The political desire for more "preventive" health care for everyone meets the shortage of primary health care providers.

८१ टिप्पण्या:

rhhardin म्हणाले...: More guys are needed. They won't visit a doctor for decades. Preventative care means getting your broken arm set.; ५/४/०८, ७:४८ AM
Ruth Anne Adams म्हणाले...: MittCare sucks.; ५/४/०८, ८:३३ AM
Peter V. Bella म्हणाले...: My mom's doctor is thinking of quitting. The record keeping, even though it is computerized is way too much and too costly to keep up with. He is a one man practice and has five clerical people working for him plus his mother. He puts in longer and longer hours and the return is just not there.

I recenly met an attorney. He studied medicine and after completing his residency went into practice. He lasted six months. He went to law school, working part time as a "mercenary" doctor; an agency sent him to ERs to do diagnostic work when they were short. According to him the "practice" of medicine has to change or the system is going to break down.; ५/४/०८, ८:३५ AM
अनामित म्हणाले...: Doctor shortage: AMA, medical malpractice insurance rates, gross punitive damages, trial lawyers, Democrats.

Next question...; ५/४/०८, ८:४८ AM
अनामित म्हणाले...: Before everyone starts to hang these problems on Mitt Romney, we should pause to consider:

Mitt assembled the best and brightest from a state well known for have a lot of best and brightest.

The current plan is what that team came up with.

With all of that, it has problem that are structural.

So isn't the lesson that getting universal health care is a lot harder than Hillary and Obama say it is, when even the best and brightest in MA create a plan with problems?

What would H or O do different from what Mitt's team did, to help solve the problems?

And even if they learn from Mitt's plan, don't we then owe Mitt a thanks for attempting a first pass from which we all then are now able to learn?

(Or we can just trash Mitt for the “failures” which is the lazy thinker's path.); ५/४/०८, ८:५२ AM
rhhardin म्हणाले...: Back in the old days, no doctor could stay in business charging more than people were willing to pay.

Moreover, a doctor's services was the Paul Samuelson economics example of no single market price (and hence what economics would not be talking about). Doctors charged rich people more, poor people less, for the same thing, because the product wasn't resellable.

Today that is approximated by regular supermarket sales. Poor or miserly (``thrifty'') people wait for sales to stock up; rich people buy more or less continuously.

Perhaps medical sales could be used to solve this thing, since the bureaucracies are not going to give up their cut of the cash flow anytime soon.; ५/४/०८, ९:०४ AM
Ruth Anne Adams म्हणाले...: I think the premise of MittCare was faulty...coverage for everyone no matter what. That's the essential first question: DO I WANT MEDICAL INSURANCE? People should be free to choose 'no' like I did when I was young, healthy and broke. I suspect MDs are going to leave Massachusetts pretty quickly and go to greener exam rooms. Unless we get universal-ly bad health care mandated nationwide...then it doesn't matter what state you're in because it'll suck everywhere.; ५/४/०८, ९:०६ AM
Unknown म्हणाले...: Bill and Hill should share their riches with those primary doctors mentioned in the NYTimes article --primary care physicians really do lose money every time they treat a Medicare patient (my husband is an internist). Once Hillary delivers her mandated universal health care (if elected President), the primary care doctors in practice now will give up the practice of medicine completely...they will not be able to afford to continue working as doctors.

The loss of respect from both the patients and the business types who now run most hospitals and clinics is also disheartening to the physician who was once considered and treated and even revered as a learned professional.

Instead of four grueling years of med school and 3-5 more years of specialty training, doctors should have become politicians. Hillary's 35 years working tirelessly for the good of others has left her mega-wealthy.

As for the marketplace setting the doctors fees--now the insurance companies and Medicare (the government) set the doctors' fees. Doctors are still not indentured servants. They cannot be forced to work for the governments idea of "fair" pay. They will leave the profession in droves.; ५/४/०८, ९:१४ AM
john म्हणाले...: rhhardin -

No, for a guy its finding out there is a 2 year wait for a colonoscopy, and the GI is not taking any new appointments, because their appointment books dont go out that far.

A physical therapy doctor acquaintance once told me that the transactional costs of his handling all insurances related to his patients now accounts for 40% of his cost of doing business.; ५/४/०८, ९:१९ AM
Omaha1 म्हणाले...: RuthAnne, I remember reading some of SC's posts on "MittCare" and how bemused he was about not being able to opt out of the expensive programs and just "go to the doctor" as needed. A couple of other posts...

You sold my birthright...

Paging Doctor Howard Doctor Fine; ५/४/०८, ९:५१ AM
Omaha1 म्हणाले...: I also recall when I was one of the "uninsured" for a few months when I was in between jobs. I went to an "urgent care center" for a bad eye infection, and the doctor wanted me to go to a hospital for a bunch of expensive tests. I asked her if I could just wait and see if the antibiotics she prescribed would improve my condition in the next few days and she agreed that was a sensible approach. I know that she was just covering herself against future legal liability but I wonder how many people would even question the further testing she initially recommended. Of course the risks of a terrible eye infection include blindness etc. but if you are educated about the extremely low probability of such, you can weigh and assume your own reasonable degree of risk.; ५/४/०८, ९:५८ AM
Cedarford म्हणाले...: Instead of four grueling years of med school and 3-5 more years of specialty training, doctors should have become politicians

No, we should figure out how we can treat a old wino coming off a bender or a welfare mammy showing up at the emergency room with a sore on her fat butt without having to require that practitioners have 11 years of post secondary school education just to look at them.

The military trains medical corpsman in about a year and a half.

Somewhere between that is a good middle ground, and I say it is probably destroying the cabal of doctors and AMA that block 4-yr RNs with specialized training from doing basic medical care and diagnosis and prescribing meds for simple conditions.

We also need a lot more nurses and the solution so far is to raid 3rd world nations and gather up their nurses rather than have an affordable system to train up large numbers of Americans for the profession.

p. rich - AMA, medical malpractice insurance rates, gross punitive damages, trial lawyers, Democrats.

Well, you got the AMA part right, but contrary to myth, the legal overhead is not a significant contributor, adding 6% or so to direct health care costs. Far greater are lack of modern IT technology in medicine, medical records, America's for profit health insurers overhead, excess capacity of equipment and overtrained specialists doing simple procedures "Only an MD is licensed to do".
Add in medicine costs Americans 20-40% more than any other nations patients, hospitals are not paragons of efficient labor management since they run on cost plus and overbilling.

I do believe you have to go after tort lawyers, cap damages from the 95,000 medical caregiver "misadventure-related" deaths each year and other nighmarish fuckups that leave patients alive but worse off than when they went for treatment - just so we reduce cost of defensive medicine and passing on exorbitant insurance fees charged by for profit malpractice agencies to the individual and all taxpayers.

And we need to end free ambulance rides for winos and illegals so they get some cold medicine, and have courts buy-in that repeat nuisance welfare and elderly visitors to ERs will be treated for free, but as a penalty for abusing the taxpayer they will wait in the ER for 8 hours before being seen unless the triage nurse thinks they have a serious problem.

*************
Ruth-Anne -

Romneycare is the first big effort by a State to reform it's health care system. No doubt it has bugs, but it is something that can now be studied and reviewed by voters and elected officials to see what tweaks it needs - while before, there was nothing but decades of empty pledges that "something will be done". One thing Romneycare did was lower insurance premiums on employers and people screwed by private insurers because they weren't "group rate" but ran a 1-person plumbing biz, etc. Rates on the latter, the privately insured, went down from 630 to 470 a month. In CT, they average 850 now for two people.

Romney didn't want mandates, Teddy and the Dems in the State Legislature did, and in this case I agree with the Dems because of free riders. Those illegals, young, and working people who would rather have the Lexus than health insurance but who have few other assets - figuring that they would spend their money as they wished and if they got sick the taxpayers would foot the bill since they had nothing to be sued for.
People should be free to choose 'no' like I did when I was young, healthy and broke.

Except all the time you knew that if you were in a car accident, or developed leukemia that "society would not just let me die, they would be morally obliged to care for me and pay for it.."; ५/४/०८, १०:१४ AM
Elliott A म्हणाले...: Without the young healthy people, the cost of the program becomes greater to everyone else. A good analog is auto insurance. Every state REQUIRES insurance for every car and driver. This being said, I feel the problem does have a real solution. None of the existing plans can possibly work. The system is broken beyond measure.

In any situation where the commodity is a necessity for life, the "market" does not work. An example is electricity or water. Over the last 20 years, the big increases in the cost of health care come from three sources: First, the hospital corporations suck 30% of the dollars out as profit. They used to be all nonprofit. Second, the insurance is so convoluted that the expense to every provider in time and personnel to collect the fees is outrageous. Third, trial lawyers (John Edwards) balloon the cost of malpractice and as in John Edwards case chase practitioners out of a state untile there is a shortage. North Carolina has a terrible shortage of obstetricians due to Mr. Edwards suing them all for birth defects which were only acts of God, not man.

The system needs to be set up as a regulated public utility where there is a known and reasonable profit along with oversight and transparency. The doctors need to be back in charge of decisions on care, not administrators. There needs to be creation of five or six prototype insurance plans which are the only plans allowed. The providers could then know the patient's coverage and so will the patient. Now, a typical internist's office may have two thousand distinct plans among their patients, and hospitals multiples of that.

If the enormous costs which have nothing to do with actual care are reduced sufficiently, there will be more money to properly compensate the physicians for their training, knowledge and skill. They can concentrate on their patients, not their business and know at the end of the day they are earning a good living. To not do these things, and to follow the Dems plans for universal health care, will leave everyone insured with no doctor to see.; ५/४/०८, १०:१९ AM
Ruth Anne Adams म्हणाले...: Cedarford: One quibble. I knew the risk when I was uninsured between my military time and my current insurer [employer sponsored]. I added medical care benefits to my auto policy during that time, figuring that was the most likely way for me to become catastrophically harmed at the time and I paid at the doc-in-the-box when I went. I was what they called self-insured.

I also think that I would like employers to get out of the business of buying insurance. I pay 1200/month for my family of 5 and it is pretty darn good coverage [it oughtta be!]. The problem is with a child with pre-existing medical conditions, I'm sort of an indentured servant until she's out of prosthetics. [never]; ५/४/०८, १०:३९ AM
Dust Bunny Queen म्हणाले...: Demanding that everyone have health insurance is basically demanding the impossible for some people. Never mind about the young who rarely need medical care unless it is for accidental or minor illnesses, what about people like my husband, who have been denied insurance coverage? How is the government going to force him to be insured? Is there going to be a special pool for people like him? Who is going to be paying for the uninsured (actually we know who...the taxpayers)

We are both self employed in two separate businesses. My husband is uninsurable due to pre existing conditions, so while I carry a high deductible, catastrophic coverage policy for myself (at the cost of more than $500 a month) he is basically flying without a net. I have been to the doctor 3 times in the past 5 years for minor issues and for an annual check up each year and I have zero medical issues and take zero medications. My total out of pocket costs for the last 5 years amounts to less than $3000, yet I have paid over $30,000 on the off chance that something catastrophic should happen. That's a pretty bad return on investment if you ask me. On the other hand, it IS insurance to protect our other assets, just as house insurance or auto insurance is to protect not just that asset but all others.

At this moment, my husband is laying in bed, white as the sheets, due a re-occurrence of a bleeding ulcer, hoping that it will stop bleeding.**

We make WAY too much money to qualify for any public assistance and have too many assets. A large hospital bill of 75,000 to 100,000would mean that we are working as indentured servants for the Hospital for the next 4 to 6 years. Just walking into the emergency room would be a $10,000 moment. It could even throw us into bankruptcy. It isn't that we wouldn't get catastrophic coverage (which this is) for both of us if we were allowed to. Fortunately we can/could afford the premiums. There are many others who can't afford to buy coverage. Who can't come up with an additional $1000 a month and who are living on the edge as it is. Where does the government think the money is going to come from?

OR....we could divest ourselves of all of our assets and go on Medi-Cal (welfare) and get full coverage just like every illegal alien or welfare queen is getting now. Become wards of the State. This is really the ultimate goal of universal health care coverage, you know.

** He is getting better. But if not. Alive and bankrupt is better than dead. Then I can stand in line with all the other welfare queens and whine "where's my check?" and demand all the government freebies. Just think how much easier that would be than working every day, paying my taxes, buying insurance, contributing to the economy and creating jobs for other people.; ५/४/०८, १०:४३ AM
rhhardin म्हणाले...: I propose a right to hair care as a demonstration project. You get haircut insurance, that covers the cost of haircuts, and so forth.

Then see what the dynamics is for barber shortages, price controls, insurance premiums and unemployment.

Full disclosure, I cut my own hair.; ५/४/०८, १०:५५ AM
अनामित म्हणाले...: I agree with martha. I have several doctor relatives, and they dread universal health care. It is simply micromanaging by the state, and when has that ever produced a good result?

It is NOT true that preventive care always reduces costs. Early detection of cancer, for instance, is great for the patient like me who survives well but means decades of expensive follow-up tests and surgeries for the carrier.

The article seems to suggest that more management by the govt will cure these access and treatment problems. Frightening!; ५/४/०८, १०:५८ AM
Elliott म्हणाले...: Has it occurred to anyone that the good doctor is not telling the whole truth?; ५/४/०८, ११:२० AM
Chet म्हणाले...: $110,000.00 a year sounds pretty good to me.; ५/४/०८, ११:३५ AM
tituszenmasterextra म्हणाले...: "It is simply micromanaging by the state, and when has that ever produced a good result?"

Right now it is micromanaging by the insurance companies.

I don't have a strong opinion on this issue but I don't think the way things are working currently is sustainable.

Do people believe we just leave it as it is currently? Does it need any changes or is it working ok?; ५/४/०८, ११:३९ AM
tituszenmasterextra म्हणाले...: 110,000 a year for a doctor is pretty poor pay.; ५/४/०८, ११:४१ AM
save_the_rustbelt म्हणाले...: I'm currently working to construct sensitivity models for use by physicians to model the impacts of various healthcare plans (I must modestly admit to being one of the country's top experts on medical office financial operations).

In one sense it is not as bad as it might be, the docs interviewed in the article clearly don't understand fixed-vs-variable costs and the impacts of incremental revenues.

By the way, a primary care doc who only averages 18 - 20 typical patients a day is slacking. Only a doc who sees a lot of acuity should be that low.

In the long run primary care is going to be a huge problem, for any number of reasons.

I've read thousands of pages on health care reform (politicians, economists, etc.) and none of them have any concept of the impact on providers, except for some veiled langugage implying that providers revenues will have to go down.

Could be a cluster mess.; ५/४/०८, ११:५० AM
tituszenmasterextra म्हणाले...: How I am doing on this comment thing Ruth?; ५/४/०८, ११:५२ AM
Elliott A म्हणाले...: The current system cannot sustain itself. The only question is when the implosion occurs.

Why study for 8 years after college to earn 110,000? A lawyer can do it in 3. These people are all incredibly bright, they could do a myriad of other things. If the pay is not there, they will!!; ५/४/०८, ११:५८ AM
Chip Ahoy म्हणाले...: “It is a fundamental truth — which we are learning the hard way in Massachusetts — that comprehensive health care reform cannot work without appropriate access to primary care physicians and providers,”

What is it, exactly, about the Liberal mind that finds it so impossible to grasp the concept of supply and demand? What? [fourteen question marks in bold] I didn't see anywhere in that analysis frivolous unnecessary visits clogging up the system by hypochondriacs and people who like feeling special or important or by people who simply like being touched once in awhile. Sadly, the only contact some people get is with their doctors so they actually look forward to it. I had bookmarked a blog by a London EMT who regaled readers with endless stories about just such people, forfeited with a hard drive or I'd link it.

My GP told me a few years ago he made more that year through his investments than he did practicing.

[Hang on, little kids from a school for deaf are delivering the news in ASL. They're adorable. They made 'em dress in plain dark clothes so it shows clearly.]

Anyway, he despises Bush. Right from the start. I thought it odd he'd complain about politics during an ordinary visit. He must like me or something. His complaint then was about a shortage of vaccine, which I didn't even want but which he was eager to blame squarely and directly on Bush. I asked him if he really though Bush could possibly be directly responsible, weren't there layers of actual medical experts between him and the POS? He snapped, "Well somebody has to be blamed!" The next visit he said he was considering quitting because of oppressive law suits --that it just wasn't worth it anymore. I commiserated because he was setting the tone and I want to stay on his good side, not mentioning Bush was the only president I ever heard address that problem directly but got nowhere with it for lack of support or cooperation. The last visit he asked me if I still supported Bush, straight out of the blue, perfectly non sequitur. I was dumbfounded that in his world if I don't complain bitterly that translates as support. He had me at a disadvantage as I was there because I took a face plant and couldn't speak well, but I managed, "It must be awfully easy to be Liberal." He also named a specialist and urged me to go. I answered, based on what he'd told me, I didn't want to. It's such an incredible bother. He pushed it, "Well, it'd be interesting to see what he says." I didn't go. He'd have to do better than satisfying interest, and besides, so far he's been medically right 100% of the time.; ५/४/०८, १२:०३ PM
Peter V. Bella म्हणाले...: rhhardin said...
I propose a right to hair care as a demonstration project. You get haircut insurance, that covers the cost of haircuts, and so forth.

The only way for that to work is mandatory visits to your hair cair specialist. Mandatory haircuts or hair styles; approved by the state of course.; ५/४/०८, १२:०७ PM
Bender म्हणाले...: Re: Universal coverage, i.e. mandatory coverage, i.e. you buy insurance whether or not you want it or need it, or we'll seize your assets and/or throw you in jail

As for the analogy of mandatory auto insurance to medical "insurance," and this idea that adding a lot of young and healthy premium payers would solve everything --
The problem is that auto insurance is true insurance. One only uses the benefits in case of an actual loss, i.e. an accident. But today's health "insurance" is not insurance in any sense of the word. Instead, we have health plans, where the plan provider pays for practically everything that is health-related, rather than merely major medical costs, such as for hospitalization and injuries. The auto insurance analogy only works if the auto insurance also covered gasoline, and everyone used their insurance to pay everytime they filled up the tank.

Besides, while forcing healthy young people to buy insurance may increase the supply of insurance funds, it also increases the demand for insurance benefits. After a while, healthy folks who otherwise would not go to the doctor for years at a time (because they don't need to) start going to the doctor everytime they get a cold -- They think, if I'm going to pay out the wazoo for health insurance, I'm sure as hell getting my money's worth. Which only ends up making the problem worse.

But all of this health care funding disaster was entirely foreseeable. What else should one reasonably expect from socialism or quasi-socialism? It is always a disaster.; ५/४/०८, १२:१० PM
Dust Bunny Queen म्हणाले...: By the way, a primary care doc who only averages 18 - 20 typical patients a day is slacking. Only a doc who sees a lot of acuity should be that low.

I hope you are joking. In an 8 hour day 20 patients would take about 40 minutes per patient. This doesn't include the doctor actually getting a lunch or break. After each visit the Dr. has to make notes in your chart that reference what you and he talked about, future treatment, progress of current treatment, writing up prescriptions and so on leaving about 15 real minutes with each patient

I don't know about you but I would like for my Dr. to be able to spend some quality time with me and ask questions about me and allow me to ask questions about my condition. I would like my doctor to be rested and alert when dealing with patients and have more than 15 minutes to spend on me.

My hairdresser spends more time than this with her clients!!; ५/४/०८, १२:४६ PM
reader_iam म्हणाले...: DBQ: I don't know a thing about California, which you do. Nor do I know how your businesses are structured or whether you have employees, or how many, or of what type, which of course would affect what regulations apply and the cost-benefit analysis. I hasten to acknowledge all of that ignorance upfront.

That done: Don't you have a medical reimbursement plan set up through at least one of the two businesses through which you and your husband works? We've had one set up for many years through our own corporate entity, and this has made a huge difference at a couple of very critical times, especially when both of us were entirely self-employed.

Just asking. Not challenging. (And, yes, of course, I do know that this is not insurance ... obviously, based on the implications of the basic information provided above.); ५/४/०८, १२:५५ PM
reader_iam म्हणाले...: I should have first said that I'm sorry to hear that your husband is having such a rough time. I hope he gets better soon.; ५/४/०८, १:०० PM
Bruce Hayden म्हणाले...: Interesting article. One, of course, wonders why the NYT is looking at MittCare. Oh, wait, he is being considered as McCain's running mate.

MittCare is one of the benefits of our federal system. It was set up by probably a smarter, better qualified, group than HillaryCare, and yet is floundering. What does that say about the potential for national socialized medicine, as proposed by at least Hillary and Obama? Of course, their answer will be that they will just put smarter people on the job. Good luck. The good thing is that there is a rapidly developing international medical practice for those who have money and can't get access to specialized care.

The basic problems I see are that health insurance is not really insurance and the government at all levels meddles way too much. One result is that there is a disconnect between supply and demand, since there is no direct connection between what is paid and what is received.

I really don't mind if people over see doctors, as long as they are paying the true cost of their overuse. In our system, they typically don't.

I also fault the government in its attempts at socialized medicine. Huge amounts of money are being spent on the last years of seniors' lives, and that money is not coming from their pockets, no matter how well heeled they are. Instead, the rest of us are supporting that through taxes, and, importantly, mandated transfer payments (note that the NYT mentioned the $20 per Medicare patient, but failed to follow through on why that was - a direct result of underspending by the government on primary care,
AND mandating that the docs take Medicare patients in many cases).

Finally, one way that some primary care providers are surviving is by using more and more NPs and PAs to handle the routine stuff. I know one pediatrician who has 3 PAs working for him. Most office visits involve seeing a PA, and the MD mostly only sees the stuff out of the ordinary.; ५/४/०८, १:२६ PM
अनामित म्हणाले...: "Right now it is micromanaging by the insurance companies."

Correct, and insurance companies go out of business when they fail--they don't fine you or put you in jail.; ५/४/०८, १:४७ PM
Ruth Anne Adams म्हणाले...: Titus: Cogent. Terse. Pithy.

You got potential, kid. Keep up the good work.; ५/४/०८, २:०१ PM
Fen म्हणाले...: One question: If the government reqiures everyone to have health care, is it reasonable for them to also mandate healthy behavior? Should the taxpayers fund medical care for someone too stupid to wear a motorcycle helemt?; ५/४/०८, २:०२ PM
janemariemd म्हणाले...: Thanks to DBQ for defending us primary care docs against number crunchers like save_the_rustbelt, who likely have little real-world knowledge of the practice of primary care. I have been in general internal medicine practice for about 16 months, and am averaging 14 patients per day, which includes 2-3 new ones or annual physicals, and I am seeing 1-2 of my patients in the hospital daily. An experienced practice manager recently told me a typical internist should see 16-18 patients per day with 2-3 new ones. I do think I can manage this, and do have those days sometimes. But I am plenty busy; my nurse fielded 45 phonecalls one day last week, in between putting patients in rooms, triaging the calls for same-day appointments, doing the paperwork for consults, insurance approvals for restricted drugs, etc. I see patients in my office 4 days per week--I need that 5th day without office visits to make a dent in the endless paperwork, never mind keep my sanity and spend some quality time with my family.

I have long thought that the MA universal care experiment was a cynical political stunt--anyone who knows about the primary care doc shortage (which has been ongoing for some time) would predict the newly-insured would not be able to find primary care doctors, given the reimbursement rates in the program. Sad to say, what really needs to happen--paying the primary care docs more for what they do (and specialists less, if you want medical students to prefer primary care as a career)--is pretty unlikely. Patients are going to have to revolt, or politicians have trouble getting good primary care for themselves or their elderly parents, before anything will change.; ५/४/०८, २:०४ PM
former law student म्हणाले...: A good analog is auto insurance. Every state REQUIRES insurance for every car and driver.

But states can't require you to drive or buy a car.

Out west here, a lot of good doctors work for Kaiser. They don't have to worry about the business side, they just have to treat patients. In a small number of cases, nurse practitioners handle routine matters under a doctor's supervision.

Payment processing overhead is high. The stepmother of a friend of mine was one of two people who did nothing but fill out insurance paperwork for a family practitioner. This is a dead loss to the economy. Another dead loss: an RN I know went to work for an insurance company, approving doctor's treatment plans. After so many years of being treated like an underling, now she gets to tell doctors what to do by rejecting their plans.

If medicine were really fee-for-service, going without insurance might work. But then many people would die in their 30s and 40s, like they used to before WW II , and the onset of Kaiser and Blue Cross for workers.; ५/४/०८, २:१९ PM
save_the_rustbelt म्हणाले...: "Thanks to DBQ for defending us primary care docs against number crunchers like save_the_rustbelt, who likely have little real-world knowledge of the practice of primary care."

For the record, I've been asked to crunch the numbers by journals who want to know the impacts on their readers and what defensive measures can be taken to protect physicians, I'm not some vile beancounter.

(My budget models are used in many, many practices and surgery centers.)

I had a nice chat with a newly retired FP last week who thanked me for helping keep his practice on track for 25 years and having a nice fat retirement. That feels good. I know a whole lot about primary care.

The patient load in a primary care office depends on mix; for example, a doc I've worked with sees a lot of complex asthma and diabetes cases, his encounter numbers are lower. On a normal day of family practice (snotty noses, BP checks, etc.) the numbers should be higher.

An internal med doc with a high geriatric load would see a lower number.

New patient work ups usually get
3x time of a routine visit, complete physicials get 4x or 5x.

Nursing home practice causes a lot of phone time and faxes, PITA.

I'm glad I didn't get to the really controversial stuff.

So Dust Bunny, I'm on the side of the docs, but I don't sugar coat much.; ५/४/०८, २:३६ PM
save_the_rustbelt म्हणाले...: janemariemd:

I'm curious, what are your top ten CPTs by percentage?; ५/४/०८, २:४७ PM
ricpic म्हणाले...: I think the most important thing is the quality of our doctors: that it be kept high. My assumption is that as is the case with everything else it gets its hands on, more government control will mean a lower, on average, quality of doctor.
It's deeply insulting, not to mention potentially life threatening, to be in the hands of an incompetent and/or uncaring doctor. On the other hand it feels like rescue to find a good doctor. I've been in both places.
Couldn't we return to the old days of doctor provides the service, patient pays doctor directly? With those who means test below a certain level paying a percentage of the regular fee and the government picking up the slack? Or is that hopelessly naive?; ५/४/०८, २:५० PM
Revenant म्हणाले...: I've wondered for a long time where all the new doctors are going to magically appear from. The ones we have right now are pretty much constantly busy, and that's WITH an alleged tens of millions of people going without medical care.

Normally the market would meet that demand, but with the government keeping prices from increasing that incentive is eliminated. So what we're looking at here is a plan to increase demand for medical care (by having the government pay for coverage), while holding costs down... without any way to increase supply. That translates to, you guessed it, a shortage of medical care.; ५/४/०८, ३:०७ PM
former law student म्हणाले...: Couldn't we return to the old days of doctor provides the service, patient pays doctor directly?

Talk to Genentech. One dose of Chinese hamster medicine is $500, and you will need many many such doses if you want your chemotherapy to work.; ५/४/०८, ३:०७ PM
ricpic म्हणाले...: FLS,

I should have included catastrophic coverage as part of the mix. But for ordinary problems surely patient pays doctor directly for services rendered is practicable, no?; ५/४/०८, ३:१२ PM
John Kindley म्हणाले...: P. Rich said: "Doctor shortage: AMA, medical malpractice insurance rates, gross punitive damages, trial lawyers, Democrats.
Next question..."

Doctor shortage: AMA, occupational licensure laws, Democrats and Republicans.

See this excellent chapter by Dr. Mary J. Ruwart showing the inherent aggression and negative impact of medical licensure laws:

http://ruwart.com/Healing/chap5.html; ५/४/०८, ३:१२ PM
I'm Full of Soup म्हणाले...: Let me stick up for Save the Rustbelt a bit. Entrepreneurial self-employed docs likely average more than 8 hours per day.

As to the article, the doctor said she makes $110,000 per year and her practice has 3,000 patients??!! What the heck is she charging her patients for a visit? Nothing? If the patient count is correct she'd be better off adopting the concierge model and cutting her patient load by charging a fixed annual fee to a select few.

Sounds to me like that doctor has a bunch of excessive costs in her practice OR that salary she quoted doesnot include all of her income.; ५/४/०८, ३:३५ PM
Dust Bunny Queen म्हणाले...: As to the article, the doctor said she makes $110,000 per year and her practice has 3,000 patients??!!

Actually, she said she pays herself a salary of $110,000. Not what her practice makes.

This would be after all of her other expenses,retirement plans, rents, salaries, malpractice insurance, other insurance, equipment etc etc etc. Plus, if she is incorporated she can also retain some of her earnings into the business. I'm guessing her gross to be about 600 to 800K or better.

And you are correct most doctors work way more than just 8 hours a day. Even so. A salary of 110K given all the business headaches and dealing with icky poo sicky people every day....she would be better off in my business. :-); ५/४/०८, ३:४४ PM
save_the_rustbelt म्हणाले...: AJ:

Allow me to defend the doc with the $110,000 income.

The total patient count can be deceptive, encounters depend on gender, age, etc.

And running a practice is expensive, the fixed cost is a bear, even in a modest practice. That is why volume becomes important; the variable cost is not a steep line generally, so volume past break even drives income.

And to me primary care docs are heroes, they keep the entire system running.; ५/४/०८, ३:४७ PM
hdhouse म्हणाले...: Twenty years ago I was living in Stockholm on assignment. I got really sick with something and went to Karolinska where I was in 5 days with superb treatment. My bill was $7 and that was a 50 Kroner charge for whatever.

Doesn't it strike us as odd that those countries that put health care as a government mandate and societal right live longer, better, and generally on a lot higher standard than we do.

Think of the $1500 you have built into each Detroit car plus the stupidity of our system. Medicare is incredible low overhead... a model to which Blue Cross et al should just even remotely aspire.; ५/४/०८, ४:१३ PM
john म्हणाले...: Rustbelt,

Since you are doing Saturday consulting, can you opine on what I wrote earlier (try to responde before NCAA's start)?

I mentioned that about 40% of the cost of doing business for this PT guy was transactional related to insurance processing. Conversely, if he didnt accept any inusrance plans, he could reduce his prices by that amount. Typical, unusual, sad?

Thanks,; ५/४/०८, ४:१४ PM
blake म्हणाले...: Cedarford--

Re RNs: Don't we raid 3rd world nations for RNs because, frankly, nursing is the "cotton picking" of the professional world?

A lot of hard, messy, occasionally horrifying work. Not very good pay.; ५/४/०८, ४:४५ PM
अनामित म्हणाले...: Like others posting here, I would appreciate some straight talk from the proponents of universal healthcare as to the major cost drivers of medicine in the US. On Hillary Clinton's web page, for example, her plan envisions "savings" of $110 billion a year to fund universal health insurance, 80% of those savings coming from just two sources: (1) "modernizing" the health care system ($35B) and (2) eliminating the tax deduction for health insurance taken by wealthy tax payers with annual earnings above $250,000 ($52B). The first number seems more like a cost than a savings to me, and the second estimate seems implausibly high. Perhaps some of the readers here can shed some light on how these numbers were derived and comment on whether they are at all reasonable. I'm skeptical.; ५/४/०८, ४:४७ PM
blake म्हणाले...: And then there are people like me.

My employer offers a free medical care plan. That just covers me--spouse and children coverage raises it to $1,700/month. (Ha!)

Anyway, taking the plan required filling out seven pages of forms.

Forget it. I'd rather be sick.

Even if I could endure seven pages of form-filling, I know that attempting to use this coverage is going to require--yes, you guessed it--more paperwork.

And my employer can, at any time, change the coverage so that I have to give up any doctor I establish a relationship with, because he's not on the current plan.

I took the free dental but I probably won't use it, for precisely the same reason. I found a dentist I liked, he managed to get himself on the right dental plan--and they changed the dental plan!

It's madness. I just want to get my teeth cleaned. The occasional filling.

A colonoscopy should I survive to whatever the recommended age is (50, I think).

Yeah, if I hit the jackpot and get one of them six-figure diseases, I'm gonna want insurance. But day-to-day?

Meh.; ५/४/०८, ४:५१ PM
Eli Blake म्हणाले...: DBQ hits it right on the nose, in suggesting why we need to keep risk pools (either a pool of employees, citizens of a state or some other pool) intact.

If everyone has to purchase insurance individually, then there will be some people (i.e. cancer survivors, or people whose families include members with a chronic health condition) who won't be able to buy insurance at any price.

After all, if you know for a fact that a person will require $100,000 in treatment every year and you are an actuary working for an insurance company then you would be a fool not to deny them coverage. On the other hand, if you are presented with 50,000 people in a risk pool, five of whom you know for a fact will require $100,000 in treatment per year then you can cover it by raising the premiums on everyone in the pool by $10. Now, I am a member of such a pool and don't require $100,000 in treatment per year. But the extra ten dollars I'm probably paying to cover the people who do is worth it, since ten bucks won't break me but I feel much more secure knowing that if in the future myself or a member of my family ever does need the $100,000 per year in treatment I will still be a member of the same pool and won't be denied the right to keep buying insurance at the same rate as everyone else in the pool.; ५/४/०८, ४:५६ PM
M. Simon म्हणाले...: The fall of the Soviet Union has taught these idiots nothing. You can just hear the voices in their head. "We are smarter than the stupid Soviets. We have Degrees from Harvard."; ५/४/०८, ५:०७ PM
former law student म्हणाले...: for ordinary problems surely patient pays doctor directly for services rendered is practicable

Any doctor's visit has three outcomes, not counting "You're fine, go home.": "You're sick, I know what you have, take these pills. You're sick, I know what you have, but I can do nothing for you. You're sick, but I'll have to run some tests to figure out what the problem is."

You can probably afford the visit and the pills, but any diagnostic effort beyond some thumping and BP will run up your bill pretty quickly.; ५/४/०८, ५:१४ PM
Eli Blake म्हणाले...: iapetus:

Well for starters we in the U.S. spend 18.3% of our GDP on health care (source). This is anywhere from one and a half times to twice what countries with socialized medicine spend on theirs (the French in particular keep costs penned in under 10% of GDP.) One can argue about the reasons why, but it is clear that some of what we pay (i.e. the cost of advertising, malpractice insurance and the profit made by the insurance companies themselves) is simply not paid in countries with a single payor system.

Now, I don't myself consider that Hillary's new proposal is strictly speaking 'universal health care,' in that it simply mandates that people buy insurance and does not provide enough to pay for it (even ignoring the fact that due to court judgements any plan that depends on using tax credits is bound to fail since courts often redirect tax credits to other people or organizations due to divorce, child care or bankruptcy filings-- I'm not debating whether they should or not, just noting that if the intent of the tax credits is to help uninsured people buy insurance, it won't.); ५/४/०८, ५:१४ PM
Swifty Quick म्हणाले...: The essence of group insurance is spreading the risk. But let's be honest about what's going on. To work it assumes --indeed requires-- X members of the group dumbly and happily paying their premiums for services they never or rarely use to offset Y members of the group who are very sick and who consume vast amounts of the resources, and for the same premium that X is paying.

The problem is that many people in the X category don't want to participate. Most of the demand comes from the people in category Y.; ५/४/०८, ५:३५ PM
I'm Full of Soup म्हणाले...: John:

40% is way way too high to collect your money.

Rule of thumb is 6-10% of the amount collected. That estimate was way off in my opinion- they miscalulated or left some costs out.; ५/४/०८, ६:१४ PM
janemariemd म्हणाले...: Well, rustbelt, I didn't mean to suggest you were vile, but certainly your original comment was simplistic. Quite frankly, I was offended by the suggestion I am a slacker because I am not seeing 18-20 patients per day. Your response to my comment indicates you do have a greater knowledge of the varieties of primary care practices than was initially apparent.

My CPT codes are not given to me in percentages, I do get (usually have to ask for them) each month's CPT code frequencies. The top 2 in terms of absolute numbers are 99213 and 99214, which are follow-up visits, for those folks not familiar with coding. I do not have alot of different codes as I do not see kids or do procedures (more's the pity--many docs maintain or increase their income by doing procedures in their offices). Family physicians who see lots of well kids, and have efficient offices, can see many more patients in a day than I do.

I think the $110,000 per year wouldn't seem so bad, were it not for the endless patient demands, fear of lawsuits, and constant threat that the income will go down due to declining reimbursement. Not to mention almost all specialties make more, and some spectacularly so! In my town I have been told radiologists can make $500,000+ per year--and they don't even touch patients!! I'll tell you how they do it: I bet the majority of x-ray reports I receive include some suggestion to order another test--usually a CAT scan, MRI or PET scan. This is deeply frustrating for me, as well as my patients--rarely do these additional studies benefit the patient. This is the reason for our expensive medicine, I believe; we spend many many dollars for services of marginal benefit at best.; ५/४/०८, ७:१० PM
Elliott A म्हणाले...: hdhouse-

Sweden is a country of 4 million well educated, homogeneous people who have a cultural heritage for following directions. The US has 304 million people, is heterogeneous and has perhaps 100 million with neither the ability to follow directions or the will to do so. Comparing us to any Scandanavian country doesn't fly. The question that follows is would you like to pay a 15 or 20 percent surtax on your income for healthcare? That is how the Swedes provide the care so cheaply, they collect he money up front.; ५/४/०८, ७:३७ PM
अनामित म्हणाले...: Eli Blake @5:14 pm:
Not to be too cynical, I lived and worked for a brief time in France and it would not be the first country I'd cite as my model. Only a few years ago 15,000 seniors were reported to have died from neglect as a result of the summer heat in France, which would be the equivalent of 75,000 deaths in the US. Neglect of elders is certainly one way to "solve" the problem of costly health care in any country.

Or perhaps we could follow the British lead and have a national health service that dictates how each person can live his life, allowing government bureaucrats to deny health care benefits to those who live "too risky" a lifestyle. Yeah, that's the ticket. We'll let the government weed the bad ones out of the risk pool and lower the costs. Problem solved.; ५/४/०८, ८:०२ PM
Joe म्हणाले...: Am I supposed to feel sorry for a profession that over-prescribes medicines and then insists you make an appointment to just renew those prescriptions?

When are people going to realize that doctors are a huge part of the problem, not the solution. It is the AMA that created and now protects a monopoly. And what about those lawyers that insist on protecting their scam of punitive damages? And the lawyers that invent culpability and then advertise widely to sue over their inventions?; ५/४/०८, ८:४५ PM
Sir Archy म्हणाले...: To Professor Althouse.

Madam,

As the Ghost of a Gentleman, now dead these 250 Years and more, I am sometimes very much troubled, when I reflect upon the great Professions of Law and Physick; how they are each of them over-burdened, from my Day to this, with Practitioners, and filled with Multitudes of Ingenious Gentlemen & Ladies that starve one another.

We may pass the Question of a Superfluity of Lawyers in silence, for this Topick is too large & diverse for this Space. It may be averred, however, that the Law is most intimately attach'd to Physick in several Ways; but 'tis more after the manner of Leeches fasten'd to Patients by Practitioners of Physick, than for any mutual Benefit; altho' there will ever be those who claim Bleeding were Healthful.

If we look into the Profession of Physick, we shall find a most formidable Body of Men & Women: The Sight of them is enough to make a Man serious, for we may lay it down as a Maxim, that When a Nation abounds in Physicians, it grows thin of People. 'Twas a Jest in my Day that an Army of Physicians were more Deadly than that of Caesar; and that to conquer the World, we had but to enroll the most active & intelligent Men of a People we would subjugate as Students of Physick.

All this is now turn'd upon its Head, for the Practice of Physick is now advanc'd to such a Pitch of Perfection that in truth it may be call'd one of the Wonders of the Age; yet in those opulent Countries of Europe where Physick is the most well-regulated and provided for by the State, we find the Way of the yet Unborn into this World block'd by the very Wonders that may keep many alive, who should have died in my Day. The Numbers of Babies born in Countries such as Italy, Spain, Germany, &c. are now so low that the Population should halve every Generation; and, if the Calculus of some be correct, will be beyond Remedy in a very few Years.

All the Bleedings, Purges, Mercurick Pills, putrid Bandages, sawings of Limbs, &c. of my Day had not accomplish'd the thinning of the People that the Marvels of the Modern World are doing. That Mankind may yet be too numerous will shortly be remedied in those Countries with the best Physick and worst Morals; and thus the Maxim of Deadly Physick is upheld. I cannot but guess at Who would take the Place of the Unborn of Europe or Japan.

Because there are too Many grown old, and because Practitioners of Physick would rather dwell comfortably in Cities, there remains a Want of them in the Countryside; for now the Government says Everyone should have Advice of a Doctor, by way of saving future Charges. Thus we now import those active & intelligent Men of previously subject Peoples, trained up in Physick to care for the aged Infirm of their former Masters, all the while preventing Births among these same former Oppressors in the most approv'd manner of Fatal Modern Physick.

If I may turn, by way of closing, from these excessively gloomy Presentments, to an Item that appear'd about the Year 1712, which shews that the Idea of the Health Maintenance Organisation (as the Modern Cant would have it) is nothing new:—

                        ADVERTISEMENT.

                  For the Good of the Publick.

        Within two Doors of the the Theatre at Hay-Market lives an
        eminent Italian Chirurgeon, newly arriv'd from Venice,
        of great Experience in private Cures.
        He maintains a Variety of Italian Leeches,
        of Great Usefulness in Refreshing & Cleansing the Blood
        of Impurities & Restoring Vigour to Those suffering
        from the Gout, &c.

        Venienti occurrite morbo.

        N. B. Any Person may agree by the Great, and be kept in
        Repair by the Year. The Doctor draws Teeth in the neatest Manner.

Trusting, dear Professor, that You should be kept in the best of Repair for many a Year to come,

I remain, Madam,

Your humble & obt. Servant,

Sir Archy; ५/४/०८, ९:४४ PM
अनामित म्हणाले...: "All the Bleedings, Purges, Mercurick Pills, putrid Bandages, sawings of Limbs, &c. of my Day had not accomplish'd the thinning of the People that the Marvels of the Modern World are doing."

Sir Archy, you are more correct than you know! As another of your countrymen once said...or will someday say, "Civilizations die from suicide, not by murder," and we are proving his maxim quite true.; ५/४/०८, १०:०५ PM
a psychiatrist who learned from veterans म्हणाले...: I understand Dr. Maguire who did a great job setting up United HealthCare has a book out and is advising John Sidney (McCain). You've probably heard some of his proposals. The doc who complained about the radiologists is on to part of it; 'Shoot the radiologists' doesn't have the same ring as 'Shoot the lawyers' but, heh, we could get used to it (and shoot some of both as depending on sappines).; ६/४/०८, १२:२९ AM
reader_iam म्हणाले...: ही टिप्पणी लेखकाना हलविली आहे.; ६/४/०८, १:२३ AM
Revenant म्हणाले...: Doesn't it strike us as odd that those countries that put health care as a government mandate and societal right live longer, better, and generally on a lot higher standard than we do.

Swedish-Americans life longer than Swedes do, actually. Our average lifespan is lower, but that's just because there are segments of our society with appallingly short lifespans.; ६/४/०८, २:३९ AM
Revenant म्हणाले...: The other problem with using Sweden as a baseline is that Sweden enjoyed enormous dividends from remaining neutral during the 20th century. Consider, if you will, that the United States would have saved around ten trillion dollars (2008 dollars, that is) by letting the Axis and the Soviets do as they pleased.

That's $30,000 per currently living American.; ६/४/०८, २:४१ AM
hdhouse म्हणाले...: john...actually there is a tit for tat here. canadian drug prices average about 40% less per dose than here in the US. That explains the US traffic to Canada for Rx drugs.

Interestingly enough 40% of the Rx cost of just about any drug is in advertising and marketing the drug - something that doesn't happen in Canada. It isn't the R&D issue at all in Canada/US or the distribution or the overall contract for bulk sale. It is all in the advertising.; ६/४/०८, ७:२८ AM
save_the_rustbelt म्हणाले...: janemariemd:

$110,000 is not enough for what you do, but unfortunately the means of driving up your income are limited.

You might want to see an article in today's Columbus Dispatch.

http://www.dispatch.com/

Would you like a Botox practice? I hope not.

By the way, a monthly productivity report (encounters, top codes and $) should be a part of your routine, helps to keep everything in focus.

Good luck.; ६/४/०८, ८:१७ AM
hdhouse म्हणाले...: actually revanant, i didn't use Sweden as a baseline. I used it as an example.; ६/४/०८, ८:१८ AM
Daryl म्हणाले...: Quayle wrote: What would H or O do different from what Mitt's team did, to help solve the problems?

And even if they learn from Mitt's plan, don't we then owe Mitt a thanks for attempting a first pass from which we all then are now able to learn?

I agree. I would further like to see the debate encompass the successes and failures of universal/government health care in Canada and European states.

America deserves a real debate about healthcare during this next election.

We deserve an unbiased media that takes a hard look at foreign healthcare systems, in addition to our own. The mainstream media will do a disservice to this country if it puts a halo on the massively problematic Canadian and European healthcare schemes.; ६/४/०८, २:५२ PM
M. Simon म्हणाले...: Re: health care.

When government controls the health care budget what do they do when they have other priorities?

Lengthen waiting lists - Canada
Determine at what age you are no longer useful - Britain
Let old people die - France

There will always be rationing of medical care. The question is: how should it be done.

I think government is the worst. Suppose you become an enemy of the state? Or an enemy of your case worker?

At least if one insurance company doesn't like yo you have the option to get another. Or do without.; ६/४/०८, ३:०९ PM
KCFleming म्हणाले...: I do not think anyone will feel too badly about doctors not making enough money. Class envy is a primary driver here, so that effect is seen as a feature, not a bug. In general, I think people want doctors to suffer a bit, or even alot, for many reasons.

I suspect a majority of people will ignore or rationalize away the warning signs coming out of yet another failed attempt at socialized medicine. And much as the NY Times ignored the crimes of the Soviet Union in the 30s (even winning a Pulitzer for their mendacity), we will continue to have Lincoln Steffenses ignore the blatant errors inherent in such coercive systems and say about Canada or Britain "I have seen the future and it works."

Most of those in favor of these giant plans see only the positives they hope will come of compulsory insurance. What remains unseen bothers me quite a bit, though, for the unintended consequences are massive and deleterious for a democracy, but I fear that little experiment is dying, too.

Me? As a physician caught in this postmodern era of medicine, I can see my options narrowing. I am at a top 10 US medical institution, and I doubt I will be practicing medicine in the US in 5 years. I will either move to Ireland (or just across the border in Canada, for private practice), or stay here and get employment in clinic administration.

Smart doctors will leave their practices. Smart young people will find something more rewarding than turning the hamster wheel faster and faster for less and less pay. And none of these warnings will make any difference at all. I wish you all good luck with the new system. My kids can rely on my advice when they see the barely competent "health corpsmen" Cedarford suggests. I expect the new system to last about 25 years before it implodes, although decay has already begun under Medicare, so perhaps I am being too optimistic.

I am glad my 3 kids avoided medical careers, as I had advised. Many of their friends did so as well, because of the stories I have told them. We're going to get socialized medicine ...good and hard. And we'll have a barely sufficient cadre of C students as doctors. That's good enough for government work, though. (And not to worry, for Senators and the rich will still have access to better care, so it's all good).

But what the hell do I know? Anyway, pretty soon I'll say goodbye to my US patients. At least I'll still be able to read Althouse elsewhere.; ६/४/०८, १०:३० PM
former law student म्हणाले...: yet another failed attempt at socialized medicine

I dream of a day when our country will have color tv and mobile telephone service, like the other industrialized countries Drinking-quality water will come from the taps, and our children will be educated with our tax dollars. And then, but only then, will we have "socialized" medicine.; ६/४/०८, ११:२२ PM
M. Simon म्हणाले...: Another failed command and control scheme:

The Bio-Fuels Scam

Let me leave you with the final paragraph - just for grins:

The fall of the Soviet Union has taught these idiots nothing. You can just hear the voices in their head. "We are smarter than the stupid Soviets. We have Degrees from Harvard."

BTW the biofuels scam is destroying the rain forest, increasing CO2, and starving the poor.

Not to worry. The geniuses who brought you that will do much better with medicine.

How do I know? They say so.; ६/४/०८, ११:५४ PM
KCFleming म्हणाले...: "And then, but only then, will we have "socialized"....."

Nonresponsive, FLS, and nonsensical. But typical.; ७/४/०८, ६:३१ AM
M. Simon म्हणाले...: What is FLS?; ७/४/०८, ७:११ AM
KCFleming म्हणाले...: "former law student"

I'm lazy.; ७/४/०८, ७:२८ AM
blake म्हणाले...: I'm lazy.

Excuse me, tovarisch Pogo, but the State requires you to contribute to your ability.

To us, according to our whims.; ७/४/०८, ६:४७ PM
Nichevo म्हणाले...: Blogger former law student said...

yet another failed attempt at socialized medicine

I dream of a day when our country will have color tv and mobile telephone service, like the other industrialized countries Drinking-quality water will come from the taps, and our children will be educated with our tax dollars. And then, but only then, will we have "socialized" medicine.

Done BSing yet? We have English guests marveling over the tap water here in NYC. In England and in Italy it's not fit to drink.; ८/४/०८, १२:४६ AM
Nichevo म्हणाले...: As for:

Color TV check
Mobile phones check
Kids educated with taxes Not very well, but check

Now did you have a reason for existing that I missed?; ८/४/०८, १२:४७ AM