Thursday, April 10, 2014

Doctors Should Get Kudos For Accepting Medicare Patients

The government's release yesterday of Medicare payment data has predictably raised an uproar among the public. The conflagration is also being fanned by a media that only sees all the zeroes in the reimbursements but don't care to dig a little deeper into the numbers to understand where all the money is going. Hint: it's not into the doctors' pockets.

While the news concentrates on the witch hunt for doctors who are supposedly raking in millions of dollars from the taxpayers, the CMS database is actually a lot more useful to illustrate how LITTLE doctors make from taking care of our elderly. We should be receiving accolades for how little money we get for treating our nation's grandmothers and grandfathers instead getting smeared with innuendo about our integrity.

If you go to the CMS website, you can download the data that comprise the payment amounts to doctors. The downloads are aggregated by alphabetical order of the physicians' names. Even then each Excel spreadsheet is several megabytes in size. You'll have to be very patient if you have a slow internet connection and an old computer. I loaded just a couple of databases, including the one with my name in it, just to see what kind of information the government is releasing about me to prying eyes. What it tells me is that we are all suckers for accepting such a pittance for Medicare reimbursements.

I only looked at payments related to anesthetic procedures. The horror story is true for all physicians but anesthesiologists already know we receive far less from Medicare as a percentage of private insurance compensation compared to other doctors. This makes the pain of taking Medicare patients particularly acute for anesthesiologists. Since anesthesiologists usually work in a hospital setting, we are all obligated to take these patients whether it makes financial sense or not.

The following is a list of procedures performed and billed by anesthesiologists that I randomly pulled from the spreadsheets to illustrate how little money they made from the program. The first column is the average amount they charged for the procedure while the second column is the average they received from Medicare.

As you can see, anesthesiologists barely make back ten cents on the dollar for interventions that have life and death consequences. Only $99 for an emergency intubation? That is somebody's life on the line. If we failed and the patient dies, or worse suffers anoxic brain injury, that $99 wouldn't even cover the lawyer's lunch bill. A brachial plexus block for only $48? It take at least twelve years of education after high school and thousands of hours of training to be able to confidently and successfully place a block. For all that hard work we don't get paid enough to take a family out to see a movie? If there is nerve injury or a catastrophic complication, that $48 suddenly doesn't seem worth the risks.

The worse news for anesthesiologists though, if it could possibly get worse, is that our reimbursements from Medicare aren't all that different from CRNA's who bill for the same procedures. Again here is just a quick random sampling of the spreadsheet. The amounts that are reimbursed are determined by complicated formulas that is beyond my scope to explain here. This tiny sample does not imply an overall trend, which will require analysis of thousands of numbers for which I'm not getting paid enough to do, as in zero.

Notice how CRNA's make nearly as much money as anesthesiologists, give or take a few dollars? Data like this along with the government's lovefest with nurse anesthetists could make medical students start having second thoughts about going into anesthesiology.

If you think these number look bad, wait until millions of patients start arriving at the hospital doorsteps with their new Obamacare insurance plans. Those reimburse at Medicaid rates, which is even lower than Medicare if that is even possible. Doctors need to show their patients and the media these numbers, not hide from them as if we have something to be ashamed of. If the amount of money we get paid for performing life saving procedures isn't enough to even get a plumber to come to your house to look at your stopped toilet, there is something wrong with the system. And Congress's and the AMA's only solution is to prolong the pain.

46 comments:

  1. really? 500 dollars for an A line? ... really? do you really think an A line is worth 500 dollars???

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    1. you ever had one done incorrectly?

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    2. really? $41 to put an A line in? ... really? Don't you think it's worth more than $41?

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    3. Worth $500? Maybe not. Definitely worth more than $41.

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    4. how about the reason why that patient needs an a-line - probably worth the $500

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    5. @ gillian, ndenunz, anonymos and all others raising eyebrows on the pricing...: I have 2 things to tell you 1). Its NOT only the price of line, it is the time and skill that a willing lay man puts in to be a physician: 12 yrs of school + 4 yrs of college + 4 yrs of medical school + 1 year of internship + 3 years of residency. I BET, you dont have that qualification, as your understanding explains it all. 2). I will ask you the price when you or your loved ones are in septic shock and need life saving procedures. Medical professionals DONT deal with computers and non-living things, they deal with HUMAN BEINGS, LIVING HUMAN BEINGS, and keep them alive. But again I bet, you WONT understand as you DONT have that insight.

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    6. @jaipurse- I was not belittling medical professionals. I was being facetious plus incredulous at the terrible reimbursement for an A-line.

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  2. Gillian obviously you have never been through medical school or residency or you would not make that statement

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    1. Everyone should be able to charge a shit ton of money for standard tasks cause, hell, what if it messes up? What if?

      You obviously have your head stuck straight up your ass and don't live in the real world. Hey, though, you're a doctor so maybe someone will help you pull it out!

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    2. Let's talk real world. Medicare now wants to pay pain docs less than $100.00 to do an epidural injection in the office. That is total payment, not just the physician payment to stick a needle within millimeters of the spinal cord. Let's consider just a few basic expenses. Malpractice is about $2000/month. Maintenance contract on the C arm, $1000/ month. RN's salary, $3000/ month. Let's not even talk about the capital costs like the cost of the c arm alone - $150- 200K paid over 5 years comes out to be about another $4000/month. We haven't even gotten into the cost of supplies, rent, other office overhead and yet we are at $10,000 a month in expenses. I have to do 100 of the those procedures just for those expenses and we haven't even covered all the expenses yet let along pay the doc a salary.

      That is the real world. So it is you, my friend that has your head where the sun don't shine.

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  3. The world's smallest violin is playing for American doctors right now.

    If you listen real, real close, you can hear the dirge playing on the breaths of the wind.

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    1. Actually, if this keeps up, that violin will be playing for the patients. Enjoy the music

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    2. I think you will change your attitude when you wind up on this anesthesiologists operating table. You will be thankful for all her years of training and you will be willing to pay her your last dollar to make sure her hand doesn't slip as she inserts that A-Line.

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  4. If it is placed without a problem, then maybe it doesn't seem worth $500.
    If it is placed, but problems occur, like major bleeding that doesn't stop in someone with DIC or anticoagulants on board, then, yeah, it is totally worth the $500.

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    1. So if there is a problem do they subtract 450 bucks from your bill?

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  5. Oh man, I really wish I could praise you more for helping people! That's the whole point, right? All the "accolades" you should be getting to perform your job? Saving and helping people isn't enough? You're in the wrong business, I guess. Poor, poor you.

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    1. It's going to be poor, poor YOU, when there are no doctors to take car of you when you are sedated and intubated in the trauma ICU after getting in a car accident on your way to church, because doctors can't afford their med school student loans, car payment, mortgage, medical license fees, and malpractice insurance. I caution anyone who is not a doctor or works in a hospital that sees the full range of patients about commenting on this subject. Seriously, you dont know what it's like for a patient to show with a problem they cause themselves and expect you and the hospital to miraculously fix them, and then expect to not pay a dollar for anything. Do us a favor, and pick the 100 ft bridge, not the 30 ft one.

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    2. I do, actually, work in a hospital. You know who else can't afford their loans, mortgage, fees or insurance? ANYONE.

      Seriously, you don't know what it's like to not be privileged. Do us a favor, quit practicing medicine and die.

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    3. I am not a doctor, and really would like to make more money in my job. What I see here are 2 professionals who work in a HOSPITAL with 2 different views. One, wanting to be reimbursed based on what he/she thinks it's fair for the work, time, experience, sacrifice, responsabilites and demands related to the profession, and other, anger, unhappy, and jealous about it. We ALL would like to be better reimbursed. I do have loans, mortgage, and family to provide for. Although medicine has been seen as a beautiful and prestigious job, I don't see it like this. I see it as a regular profession, that is actually being rape by JEALOUS. A lot of us would like to be a doctor, but cannot or wouldn't make the sacrifice for. Medicine is raped by insurance companies, lawyers, and industry making other professionals become doctors and care for patients the same way but without nearly the same training. A clear example are nurses. I read above about the trainning to become a doctor "12 yrs of school + 4 yrs of college + 4 yrs of medical school + 1 year of internship + 3 years of residency". It's crazy!! Nurses, please be nurses (we need nurses), or if you wanna be a doctor, do a PHD, but work as a (doctor) nurse, or go to medical school. Our health system is too F** up, and needs to get organized again like a beehive. We don't see female worker bees wanting to bee the queen. Again, we ALL want to get better reimbursed. Please doctors don't quit, just make sure you continue being a good professional, sacrificing your life (studying) and caring for us. And you hospital worker, continue improving yourself and become a better team player. I promise I will give you both the best haircut I can. I will charge each 12 bucks and tips are welcome. Thank you.

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  6. Doctors are continually expected to be the martyrs for the healthcare system. They are constantly screwed over by the people on the business side of medicine--the insurers, the hospital administrators, the malpractice lawyers, etc. It's pretty sad that people are willing to wield the sacred Hippocratic Oath against doctors. Doctors are constrained by ethical guidelines, but when they are negotiating in the same playing field as people without ethics, they don't stand a chance. How is it fair that a major hospital system can take over all the hospitals in an area, tell doctors who have been working there for decades that they now will make 1/2 of what they used to for twice as many hours/patients or they can move 200 miles away because they won't find work at any of the hospitals owned by the hospital system. In any other profession this would yield an organized response by the labor, but it is illegal for doctors to organize in this fashion because of their Hippocratic Oath. Tough luck, docs, if you don't work like a dog for half pay you are responsible for anything bad that might happen to these people. Of course the executives putting this policy into place aren't at fault! Look at these greedy physicians! All they care about is money! Got to have money to pay for the corporate jet and two personal chefs for the board of execs, right? These are necessities for a major health system!

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    1. You apparently have forgotten the nurses who keep patients alive while the doctors are in their offices or in OR or anywhere else and do it with far less remuneration. And yes, I was an ICU nurse and an OR nurse and frankly, the CRNAs I worked with were competent and able to do as much as the MDs at the head of the table. I did not work with open heart cases, so perhaps there is some benefit there. Just like nurse practitioners are able to deal with the basic care many well patients need, so, too, can CRNAs do well in basic cases. And if your patient has DIC and/or anticoagulants on board, it is risky for anyone doing an arterial stick (and yes, I am an old enough nurse that I did arterial sticks while in ICU). Critically ill patients are risky. Most the patients coming through OR were not critically ill but having routine cases done.

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    2. You are a complete retard if you think that CRNAS can do just as much as MDs. You don't even know what you don't know.

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  7. i believe doctors should get paid fairly for their expertise just as other professions and certainly enough to pay back their student loans! But I REALLY wish the doctors want to perform these procedures to help save lives and not because it "makes financial sense"!

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    1. Wanting to save lives is a noble cause, and I'm sure that physicians want to do so. But if they cannot afford to survive, really, be able to afford more than just the necessities, why would they take the time and effort to go through med school? Doctors don't make nearly enough for what med school costs. Direct salary is good, but lifetime salary is not enough.

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  8. Maybe the ASA could lobby to get at least equal pay of CRNAs (the above figures). It looks like they charge more and get more. HA good luck ASA. A little effort would be nice to see. Now we have a CRNA as the president, it's over.

    Everyone here is obsessed with $500 A-line. If you do a small bowel resection with an A-line before the patient goes under anesthesia it is because they are VERY sick. You will be busy and working hard to keep them alive, among other things. If you do the same procedure on a different patient that doesn't need an a-line, VERY different anesthetic. A difficult A-line placement and set-up can take well over 30min (tubing pressure bag setup etc). My plumber charges $70 for the half hour.

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    1. A. If it's not difficult, it takes 10 minutes, making the average rate well above $200/hr for that procedure.

      B. Unlike the plumber, you pay nothing for the materials.

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  9. To those who understand, no explanation is necessary. To those who don't understand, no explanation is possible. Being an Anesthesiologist is a thankless job. No one really understands what we do. Most people don't understand the amount of time and sacrifice it takes to become one. Unless you have had the experience of keeping someone alive, you cannot possibly comprehend the enormity of that responsibility and the personal cost of doing this 50+ hours a week (after 16 years of100 hr weeks while going into 100k+ debt) You can't understand what it takes from you when you lose a patient, even if you did everything right. We have no sick days, paid vacation, retirement, workers comp, or benefits. Most of us did not know the reality of what this job would entail and how things would change. Most people don't know that doctors have a shorter life span on average due to the stress of the job. Most people think it's easy and we have all the answers because that's what they see on TV. That we work 20 hours a week and golf on Wednesday. I don't know any doctors that work less than 50 hours a week. It's even more when you take call. We can never have a bad day at work or make a mistake because someone could die or get seriously hurt. Having a job where mistakes are not allowed is asking someone to be perfect. I think only police officers, pilots, and air traffic controllers are held to that standard. And yet we are human . Again, you can't know what that does to a person unless you have experienced it. We became doctors because we wanted to practice medicine and help people, not run a business. Everyone wants to be appreciated for their work. Even doctors. It's unfortunate that money has taken over medicine, both for the doctors and the patients. I worry about who will take care of me when I'm old. Not all doctors come from a privileged life. I was born into the foster care system and when I did get adopted, I was the first person in my family to graduate from college. I think it's always interesting how the most angry people who post, never put their real name. Clearly that person is very angry about something. I think our only hope is to educate people. But not everyone is interested in learning. If it was an easy answer, it wouldn't be such a complicated problem.

    How much should doctors get paid?

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    1. Somewhere along the lines of ( E ("education cost") + W ("Lifetime Working Hours Including Med School") * 5) * n ("Years Experience") / 5, or ( (E + W * 50) *n / 5) per annum starting during residency?

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  10. Do not complain about CRNAs while simultaneously complaining about Obamacare. Anesthesiologist salaries, like those of many physicians, are artificially elevated by licensing, regulation, quirks of the medical system, and cartel effects. These are all anti-competitive, anti-market forces; they are the reason why you make so much, not supply and demand for your life-saving services. So don't turn around and pretend that you're John Galt when Obama proposes modest systemic reforms.

    I can say as a surgeon that *most* anesthesiologists are WAY overpaid. An anesthesiologist has a much easier residency, works fewer hours, and has less responsibility than a surgeon. Yet, they almost always make more than a starting surgeon. Why?

    Don't get me wrong, hats off to anesthesiologists in big centers running ICUs and managing patients in the toughest cases. That takes skill and I want you on my side. But for the other 95% of cases, your lumpectomies, biopsies, et cetera - give me a break. Anesthesia simply isn't what it used to be. Technology has made it much, much safer than it was even a few decades ago.

    So safe, in fact, that in most cases it can be safely practiced by a well-trained nurse. There simply isn't evidence showing that nurses can't do the job in most cases with equivalent outcomes, no matter how badly anesthesiologists want that evidence to exist.

    There is a reason nurses don't just get an extra year or two of training and then compete with surgeons for cases: surgery is still really, really hard. When the patient dies on the table, both the surgeon and the anesthesiologist are to blame but guess who the family thinks is responsible? The anesthesiologist isn't the one who saw the patient in clinic and decided surgery is the right answer. The anesthesiologist also doesn't round on the patient daily on the floor, or in the ICU. They don't get called in from home when the patient returns with an abscess. Frankly, the buck has to stop somewhere, and it doesn't stop with the anesthesiologist, it stops with the surgeon.

    If a nurse could do my job as well as I could, I would admit that maybe I am overpaid in some situations and take a paycut. Moral of the story: If you don't want your job to be replaced by a nurse, then choose a specialty that is beyond the ability of a nurse to safely perform.

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    1. Ha ha ha, I work with you. Not surprised a surgeon would say this. I hope everyone you meet kneels out of respect. You truly deserve it. Honestly I was so blessed to read a surgeon's opinion -let's be honest is there any other- on the feild of anesthesia.

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    2. Why does a radiologist make even more? Just because you round on a patient doesn't mean you get more. It's all about lobbying, radiologist and surgeons have great societies that keep mid levels out. ASA doesn't care

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    3. Good example of the "smart" surgeon who does not understand anything other than what is going on in his "field". A lumpectomy for you maybe like any other lumpectomy, but a lumpectomy in an obese, difficult airway patient in whom you actually except and GA while requesting a MAC is different(just an example) . Any of these cases you mentioned as easy can go south from an anesthesia perspective depending on what the patient comes with. Try to understand a little bit what is going on with the rest of patient and if you cannot, spare us your opinions!.

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  11. How are doctor's part of the privileged class? A majority of the physicians are immigrants because they realize that is one of the few professions that reward intelligence and hard work. The privileged already have jobs on wall street hooked up for them before the got out of college.

    It's not even the doctors that are billing for such a high amount for procedures. It's the billing company that, yes, for the benefit of the doctors, try to game the system too.

    If you bill a large amount, 9 out 10 times you'll get pennies back, but 1 out of 10 times you may just get 80% of what you billed for. Sure, that's a good pay day which help average out the very low reimbursement from the other 9 procedures.

    I admit that doctors try to game the system too, but only because the insurance companies are putting the squeeze on the doctors. In a pure fee for service free market system, no doctor would try to charge $500 for an arterial line.

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  12. Why shouldn't CRNAs be reimbursed the same amount for completing the same procedure with the same outcome when compared to an anesthesiologist? While not an anesthesiologist by far, CRNAs have gone through at least 6 years of school after high school and at least 1 year of working in an ICU, many do more than this minimum.

    As for the reimbursement for advanced practice nurses, many are employed and salaried by hospitals, in which case they "bill" for the sake of the hospital, not for their own personal reimbursement. This means that if a nurse practitioner inserts an arterial line, the hospital bills the insurance company for however much money, but the nurse practitioner doesn't actually make more for putting in that line - they have only proven to the hospital that they are a worthwhile employee.

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  13. And of course we are led to believe women doctors only get 77% of what male doctors get.

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  14. Everyone passing judgment on who is making too much and who is not needs a lesson in free market economics. Otherwise, move to Cuba and then you will be at peace with your government's judgment on "fair" wages.

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  15. Agreed. Government shouldn't decide fair price, the market should. And if you can't afford the market price for something, just like everything else in this country, you only get the services you can afford. If you can't afford car insurance and drive without it and then get into an accident, you're fucked. No one tells the mechanic he has to fix your car and how much he's allowed to charge you. If you don't like his price, go somewhere else. Being a physician, at the end of the day, is a job. We should be paid as the free market decides it. No one on here in any other profession is paid less than what the market decides is fair for the skills that you have. And you would be pissed if government decided that everything you worked your life for is only worth "x" when the free market would say otherwise. And if you're being paid less than that, you should find another job that reimburses you at the level of your qualifications. Healthcare and physician reimbursements should be no different. Let the market decide how important their health is to them. If you don't want to pay a certain price for treatment, then go to the hospital that charges less. Eventually hospitals and physicians will become competitive, the public will actually come to understand the real cost of healthcare (like how they know one item they want is cheaper at Target than at Wal-Mart) and stop thinking it's supposed to all be free, maybe they'll start taking better care of themselves because they don't want to risk having to spend so much money on a CABG later down the road, and they'll prioritize having health insurance...and prices and reimbursements will finally even out to what is indeed "fair".

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  16. As an anesthesiologist with almost 10 years of practice under my belt after residency I would say while I absolutely love my job and enjoy what I do if I had the chance to do it all over again I wouldn't have wasted 10 years and $250,000 on medical education and residency when I could have gone to nursing school and ended up in the same place. CRNAs in our group make half as munch but they work half the hours so they effectively get paid the same salary and when things go wrong, well they're just nurses and practicing under a physicians supervision so the anesthesiologist takes the hit and they keep working as the employees that they are. Some of my CRNA colleagues work two full time jobs and make more than I do! I have reviewed many malpractice cases in states where CRNAs have independent practice and in every one the physician, be that the anesthesiologist who is lending his or her medical license to the nurse or the gastroenterologist or psychiatrist who is the physician "supervising" the nurse (even though they have no idea what anesthesiologists do or ho to do it) or the surgeon who is performing surgery and AT THE SAME TIME supervising the CRNA, are responsible for any errors they make. When are people going to realize that nurses already make the same as physicians who administer anesthesia and yet have little or no responsibility?

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  17. I find the entry by the surgeon hysterical! Every Anesthesiologist works with "that guy". He is the surgeon that yells at everyone in the OR when he is nervous because things in the surgery aren't going well. He is the surgeon that says "don't do a GA, just do a MAC with an LMA. He is the surgeon who blames the equipment when his skills are failing him. He is obsessed with having EVERYTHING his way to the point of OCD, including the music. He has to control the conversation during the case and it is usually about how great and talented he is or how much better a surgeon he is than his colleagues. We put an 18g IV in your patients because you lose more blood than everyone else. When you blame the depth of anesthesia on a patient moving during a MAC case, we know the problem is with your skills in placing local anesthesia and that when you say MAC, we know it's really a GA with a mask. You complain about everyone you work with when you don't get your way. To you sir, I say don't be jealous because we make more. Work on getting paid more for your own cases. I think you deserve more than what you are getting. You choose to be a surgeon, you could have been an anesthesiologist.. And watch your back, because the PA that closes your case is a few years a way from being granted privileges to do your case in underserved areas. With time they will be doing your cases at your hospital. Unless of course you are retired by then.

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  18. As a physician, internal med, seeing crna's bill the same for procedures is terrible.

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  19. I'm laughing at all these anonymous comments. Even the blogger has hidden his identity. If your comments are defensible, you shouldn't be afraid to link them to your name. It might make this whole discussion more civil.

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  20. ur idiots. go get sick. ull beg for a doctor. dont think ull beg for a crna.

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  21. Why would anyone be a PA

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  22. Well, the article was extremely poorly written. The billed prices are inflammatory. I don't know how Medicare can state $500 for an a-line, the Asa value is 3 units, I know for a fact we "bill" $100 a unit so that would be $300, our best contracted rate is $65 so that is $195 for an arterial line. No one has discussed billed vs contracted rates. As billed rates are in la la land and no group ever collects even close to the billed rate.

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