I just got a post card offering a MOC preparation course for $1350 !! This is on top of the fees already in place, the cost of continuing medication courses, and the value of my time. MOC is one more fine reason NOT to go to medical school. One more little know reason for a doctor shortage - the Hassle Factor makes it just not worthwhile.

2014 will be even more interesting. Many major elements of Obamacare are supposed to kick in. The states have, for a variety of smart or apathetic reasons, not been active in setting up the state insurance exchanges. Perversely this may protect a swath of Americans for a few more years, if their employers continue to carry health insurance as opposed to paying the fine and telling their employees to go to the exchanges for insurance.

Interesting. I had not made the connection between Max Baucus' departure and the ACA. I wonder if Kathleen Sibelius feels the edge of the cliff under her toes, because she will be the Obama administration's sacrifice in 2014.

At the national level I do not believe anyone is particularly concerned about the reduction in training that work hour limitations has caused. They prefer to reduce the independent decision making component of medicine. If clinicians are basing 80% of their judgements on evidence-based medicine using an EHR-embedded care protocol, how much time should be spent learning to make the other 20% of those decisions. Ya just have to hope that you aren't one of those 20% who needs an experienced clinician or a technically superb surgeon.

Whether or not you think that non-MD / DO health care providers are a good, an evil, or a necessity you should know who is treating you. You should never be embarrassed to ask directly, if it is not obvious from the ID badge. The important message is that the title "doctor" has been aggressively co-opted by non-MD / DO health care providers so don't assume that someone referred to or introduced as "Doctor Smith" (doctorate of nursing practice) is an MD / DO physician. And don't be shy to ask.

But do you know the different between an ophthalmologist and an optometrist?

Everything Dr. Scherz said is spot on. I am relieved to live and practice in North Carolina which is not expanding Medicaid. My practice is currently 70% medicaid. Although expanding Medicaid enrollment might in theory increase the number of patients I care for, this would absolutely have to come with reduced payment for my professional services otherwise the books would never balance. If you lose money every time you see a patient, you can't make it up on volume.

The problem is that the financial ill health of the country is biting before the transition to ObamaCare economics could take hold. If all seniors are in ACOs (accountable care organizations) then the SGR is broadly irrelevant. In this scenario, if the SGR takes a huge hit / cut, it affects a small number of independent physicians still foolishly participating in medicare. In a black humor sort of way, I kind of hope the SGR cut lasts a good 6 months as so many practices will go beyond refusing new medicare patients and actually start dismissing their current patients. If it costs you $40 to see a patient and you get paid $20, you can't make it up on volume.

Currently my practice is about 70% medicaid, because I am a pediatric surgical subspecialist working in a poor part of the country. If I wasn't supported by the practice, which feels that I provide a critical service to the community, I would have left long ago. My gross pay is barely at the level it was in 2005, and there has been plenty of cumulative inflation since then. Salaried job? I'd love one. Can I have 4 weeks of vacation, 2 weeks of educational travel, and a built-in cost of living raise? I would most definitely work less hard and (in my unusual case) probably for more money. Why shouldn't I? I've been in this game 17 years and the rules keep getting worse and worse.

For those who have commented that doctors "get caught doing unnecessary operations"...you may be interested in some recent activity in Congress about medicare fraud audits. These were brought under sharp scrutiny because the fraud investigation process was costing the government a lot of money and recouping very little! In reality the investigations were intended to be self-funding because the auditors get a cut of all "fraud dollars". But surprise!! MOST doctors are honest, hard working folks who are not out to rip anyone off.