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In a recent article in Forbes Magazine, John R. Graham wrote:

"But few of these [small medical practices] will survive Obamacare. Practices small and large are being bought by hospitals and health plans, and most observers agree that few independent practices will remain if Obamacare survives its legal and political challenges."

There is simply no way to be tactful in response to this statement.  It reeks with dishonesty.

In a recent article in Forbes Magazine, John R. Graham wrote:

"But few of these [small medical practices] will survive Obamacare. Practices small and large are being bought by hospitals and health plans, and most observers agree that few independent practices will remain if Obamacare survives its legal and political challenges."

There is simply no way to be tactful in response to this statement.  It reeks with dishonesty.

Small medical practices across America are in trouble, deep trouble, already.  Their troubles have nothing to do with the coming of "ObamaCare," which is more than 2 years away.

As the Administrator of a small internal medicine practice, I can share my experience, which I am sure is the same as that of many small medical practices.  The failure of small practices are due to the following:

Reimbursement to primary care physicians has not increased at all in the past 20 years; at the same time the cost of health insurance is up 131% over the last 10 years. The massive role of the insurance company in health care serves no purpose other than to transfer money from the health care providers to a group of people who provide no services, yet saddle the small practices with mountains of paperwork and regulations.  Yet these are the very same "industry people" who consistently complain about "government regulations."

The administrative costs of dealing with private insurance can be as high as 14% of annual revenue.  As a practice administrator, whose practice sees nearly 70% Medicare patients, and 30% private insured patients, we incur a cost as high as 7% just to be able to submit our bills to these private insurance companies.  Let me repeat, the 30% of our patients who are privately insured are in fact responsible for nearly 90% of our billing related expenses.  

Related to the above, every insurance company has its own set of rules.  Every insurance company has its own set of tricks to delay and/or avoid payment to a physician for as long as they can.  One such trick is the "we need your Tax ID number trick."  This usually occurs at least once a year, from a company that has been sending the practice checks for the past 8 months.  How is it, all of a sudden, they need the Tax ID before they can send out the next check?  Did all the Tax ID's in their computer system get erased by the IT intern? I doubt it.  Every doctor in private practice will tell you the same story: there is no greater threat to their existence than the Health Insurance Industry; ObamaCare is yet 2 years away.

To get a grasp of the shocking amount of money sucked out of the health care marketplace by insurance companies one only has to look at the retirement package provided to former United Health care CEO "Dollar" Bill McGuire, who was walked away from his health insurance company with more than $2 billion in his retirement package. This same pattern is par for the course in private health insurance companies. The median CEO pay in 2010 was $10 million dollars.

To use a Matt Taibbi description: The health insurance industry is a giant vampire squid wrapped around the heart of the American health care system, relentlessly jamming its blood funnel into anything that smells like money.

If one places this income inequality in the context of the recent CBO report, it is easy to see the stark contrast in the health care industry when you compare the income gap between the "providers of health care services" to that of the insurance company executives, with the providers being to do more and more for their patients, while the insurance executives compensation continues to escalate.

But to read Mr. Graham, it is ObamaCare that will kill small medical practices...ObamaCare will not kill any small practice, they will already be dead!

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  •  Tip Jar (140+ / 0-)
    Recommended by:
    cv lurking gf, Otteray Scribe, oldcrow, BoxNDox, MadRuth, glorificus, Sunspots, OleHippieChick, BarackStarObama, MartyM, Chi, Lorikeet, JayDean, mlharges, We Won, shaharazade, middleagedhousewife, DrCoyle65, maggiejean, Hear Our Voices, DWG, fiddler crabby, where4art, eru, science nerd, Teknocore, watercarrier4diogenes, 3goldens, smileycreek, monkeybrainpolitics, ferg, arendt, third Party please, historys mysteries, ArtemisBSG, kurt, Matt Z, lineatus, CoolOnion, Shockwave, haremoor, Unbozo, SteelerGrrl, A Person, tomjones, Book of Hearts, Amber6541, Bernie68, jgilhousen, J Orygun, james321, raptavio, gooderservice, Shahryar, Native Light, Wek, albrt, arlene, TheMeansAreTheEnd, divineorder, G2geek, mrsgoo, Getreal1246, MrHinkyDink, wasatch, artebella, Christy1947, Mr Robert, madgranny, mamamedusa, zerelda, terabytes, ms badger, NoMoreLies, happymisanthropy, bnasley, vacantlook, Kane in CA, greengemini, Wee Mama, wayoutinthestix, shayes, Joe Bob, celdd, fixxit, dotsright, Amor Y Risa, Bluerall, devtob, Bill in MD, HarpboyAK, CTPatriot, begone, MsGrin, Rosaura, Pohjola, CarolinNJ, Funkygal, splashy, DiegoUK, riverlover, Lily O Lady, yaque, J M F, SneakySnu, Angie in WA State, Clive all hat no horse Rodeo, SoCalSal, Showman, sb, skohayes, Tinfoil Hat, Robobagpiper, samddobermann, Creosote, matx, marleycat, erratic, blue jersey mom, crystalboy, coppercelt, whoknu, Geenius at Wrok, Hoghead99, KalHermit, mikidee, Thinking Fella, Nulwee, Blueslide, molecularlevel, happy camper, flowerfarmer, bronte17, nzanne, NBBooks, buckstop, Byron from Denver, glynis, Gustogirl, triplepoint

    "The illiterate of the 21st century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn." ~ Alvin Toffler

    by gkfahnbulleh on Thu Nov 24, 2011 at 12:22:32 PM PST

  •  Yeah, but doesn't Obamacare make the health (11+ / 0-)

    insurance industry even stronger?

    •  Depends on how you look at it (23+ / 0-)

      It gives them a lot of new customers, but also places a lot of regulations on the industry.

      •  Regulations that will ultimately be determined (15+ / 0-)

        and interpreted by regulators under the control of politicians who answer to insurance companies.

      •  "a lot"...? understatement of the year. (8+ / 0-)

        The "personal mandate" gives them 100% market share.

        That's not "a lot", that's called "having it ALL."

        And if government gains the power to force individuals to buy products from private companies, the logical outcome will be the end of Social Security and mandatory 401Ks.  Goldman Sachs is probably drooling over this one already.  

        "Minus one vote for the Democrat" equals "plus one vote for the Republican." Arithmetic doesn't care about your feelings.

        by G2geek on Thu Nov 24, 2011 at 05:23:08 PM PST

        [ Parent ]

        •  Do you mind taking me through... (4+ / 0-)
          Recommended by:
          G2geek, sb, samddobermann, ban nock

          ... how we get to the logical outcome you mentioned? I don't follow.

          Hyperbole will be the death of us all!

          by MrHinkyDink on Thu Nov 24, 2011 at 05:58:17 PM PST

          [ Parent ]

          •  sure, it goes like this: (13+ / 0-)

            There is no power in the Constitution or in case law, by which government can force individuals, as a condition of their mere existence as citizens, to conduct business directly with private companies.  

            What Congress dreamed up here is an entirely new government power.

            If the Supreme Court endorses it, government will gain it as a generalized power.  And as we've seen, generalized powers expand to fill every niche, for example all the excesses of the Bush era.  

            The general power is the power to require individuals to purchase products directly from private companies, whenever there is a "rational basis," under threat of a legal penalty.  That legal penalty is a "tax" only in name, clearly not in its intent as seen through legislative history.  Though if you want to call it a "tax," it's one of the most outrageously regressive taxes on the books.  

            This is NOT the same thing as e.g. offering a tax rebate for people who put solar on their house or whatever.  Those rebates are rewards rather than penalties.

            To structure it as a tax rebate, it would have to be a tax break commensurate with the costs involved.  Clearly that isn't going to happen; it was never on the table.

            The other way around this would be with a generalized tax increase offset by a rebate.  But then comes the sticky question, what does the tax increase pay for?   And the logically inevitable answer is, it would pay for the public option!  

            Once you have the public option in the mix, what you have is a perfectly ordinary scenario:  a tax increase to pay for a new government service, and a tax rebate to reimburse those who choose to provide that service for themselves in some other way e.g. by buying private insurance.  That's legal under present Constitutional law.  

            However, minus the public option, what you have is the naked government power to compel individuals, as a condition of their existence (rather than in conjunction with an optional activity such as driving a car) to purchase a product from a private corporation.  

            Once you have that power standing alone, it can be applied wherever an administration and Congress can justify a "rational basis."

            Thus, on the "rational basis" that Social Security "is going bankrupt," government could require individuals to purchase "retirement products" from private providers, and structure this so as to constrain the market to a specific set of private providers (as is done with insurance products).  

            At that point, pragmatic politics kick in, the lobbyists swarm DC, and the result is that the regulation is structured to require purchasing those "retirement products" from an "approved set of providers," namely the too-big-to-fails, the bankster banks, Goldman and their ilk.  

            As well, consider how the entertainment industry has managed to get copyright law tweaked to the point where the latest bill gives them the power to unilaterally shut down websites that are "deemed" to have "infringing content," such as for example dKos after a Republican troll posts a bootleg of a first-run movie in its entirety.  Go look up that bill and the comments from EFF and other defenders of freedom of speech online.  

            That's one example out of many, of how lobbyists and vested interests can tweak laws to suit themselves.  Now apply that to the present circumstance, and what you have is every vested interest seeking to install a government mandate upon citizens to buy their particular product or service.  

            What kind of twisted shit may emerge from this, is anybody's guess.  But it's not too far-fetched to envision government-mandated Christmas shopping during any year when "the risk" of a recession in the retail industry "threatens" the economy at-large.  

            If the power is granted, it will be used, in ways we can barely envision.  Mandatory 401k's from bankster banks are just the tip of the iceberg.  

            "Minus one vote for the Democrat" equals "plus one vote for the Republican." Arithmetic doesn't care about your feelings.

            by G2geek on Thu Nov 24, 2011 at 06:50:04 PM PST

            [ Parent ]

            •  Or maybe . . . (5+ / 0-)
              Recommended by:
              CarolinNJ, sb, Robobagpiper, Jagger, G2geek

              . . . government-mandated health club memberships. Or maybe purchase of a car not older than five years for safety and air pollution reasons.

            •  Very logical concern (2+ / 0-)
              Recommended by:
              sb, G2geek

              Which way do you think the felonious 5 on the SCOTUS will go on this? I suspect they are heavily conflicted on this issue. On the one hand, they claim to support states rights, and a federal government overriding the insurance laws of individual states and forcing citizens to purchase private insurance would certainly be a violation of that right wing constitutional mantra. On the other hand, their corporate masters will be demanding that they find in favor of the individual mandate because it will be good for commerce and good for the economy (their argument, not mine).

              Considering that their belief in states rights is easily thrown overboard when right wing victory requires it (such as Bush v. Gore), my bet is on the felonious 5 ruling as a block in favor of the individual mandate. They may even be joined by some or all of the "liberal" justices who wouldn't want to be seen as voting against Obamacare.

              •  if the individual mandate goes (0+ / 0-)

                then the exclusion for preexisting conditions and all it entails stays.

                Period. End of it.

                Before you start guessing outcomes you need to learn more about the court and also the existing legal precedents.

                I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

                by samddobermann on Fri Nov 25, 2011 at 05:38:29 AM PST

                [ Parent ]

                •  That's not necessarily true (1+ / 0-)
                  Recommended by:
                  kareylou

                  The courts have been divided on the severability issue. At least one court has ruled that if the individual mandate goes, the whole law goes down with it.

                •  If the individual mandate goes, the whole thing (0+ / 0-)

                  goes. You cannot have a pool of only sick people paying premiums. You need healthy ones not drawing on the medical services at the same time, or it is just too expensive to cover the sick ones.

                  Medicine is expensive. Yes, the drugs may be a racket, but the people taking care of you deserve to make a decent living also.

                  Sophisticated machines cost big money also.

                  He's a walking contradiction, partly truth and partly fiction. Kris Kristofferson

                  by glorificus on Fri Nov 25, 2011 at 12:16:01 PM PST

                  [ Parent ]

                  •  per my comment below, all of this.... (0+ / 0-)

                    ... becomes a non-issue the moment the public option is in the mix.  ALL of these issues simply cease to be issues.

                    The ONLY reason why ANY of this is a problem is because our economy is suffering the "flea anemia" of having its blood drained by a parasitic class of overcompensated middlemen.  

                    We've twisted up the entire health care debate around the central issue of "how to keep the insurance industry profitable" rather than "how to provide Americans with health care."  That's like a family organizing itself around a substance-abuser: it's not healthy for anyone concerned, it's by definition an unhealthy family system.  

                    So the first thing to do is fix the substance abuse or divorce the abuser: rip the private insurers' claws off the levers of power, and then reconfigure the system around the actual goal of "how to provide Americans with health care."

                    "Minus one vote for the Democrat" equals "plus one vote for the Republican." Arithmetic doesn't care about your feelings.

                    by G2geek on Fri Nov 25, 2011 at 08:55:44 PM PST

                    [ Parent ]

                    •  The only argument I have with your comment (0+ / 0-)

                      is I see very little chance of immediately causing the private insurance companies to evaporate. It's a process, like getting schools desegrated or women the vote.

                      Saying the works "public option" does nothing. Educating the public is needed.

                      He's a walking contradiction, partly truth and partly fiction. Kris Kristofferson

                      by glorificus on Sat Nov 26, 2011 at 03:42:50 AM PST

                      [ Parent ]

                •  all of which becomes a non-issue.... (0+ / 0-)

                  .... with the public option.  

                  ALL of these nasty stinky items become non-issues with the public option in the mix.  

                  "Minus one vote for the Democrat" equals "plus one vote for the Republican." Arithmetic doesn't care about your feelings.

                  by G2geek on Fri Nov 25, 2011 at 08:51:00 PM PST

                  [ Parent ]

                •  Legal Precedents? (0+ / 0-)

                  Since when did the Roberts court give a flying f*ck about legal precedents?! Maybe you need to learn about the behavior of today's Supreme Court before so arrogantly lecturing others.

            •  All medicare D plans are with (1+ / 0-)
              Recommended by:
              mikidee

              private companies. You must buy one as soon as you go on Medicare unless you have credible other prescription coverage (like from an employer).

              If you don't go on as soon as you should your premiums go up I think it's 1% each month you delay. So if you put it off a couple of years you will forever pay 124% of what that insurance company charges for their insurance.

              The ACA empowers people to start up their own nonprofit insurance corp. A state can set up a single payer system as they are in VT. There are alternatives.

              If you could actually think of how single payer could have gotten through let us know. and No, Obama hammering away on this for 4 years would not have made a difference.

              I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

              by samddobermann on Fri Nov 25, 2011 at 05:30:12 AM PST

              [ Parent ]

              •  quote Shakespeare but substitute.... (0+ / 0-)

                ... "health insurance executives" for "lawyers."

                Seriously.  OWS and its ramifications may get us an answer, we just need to put it on the agenda.  We've already got the banksters scared, may as well add another batch of parasites to the "scared" list.  There need to be health care equivalents of credit unions: member-owned cooperatives with the actual resources to provide the actual health care.  Once those alternatives exist, people will begin using them, and the power will begin to shift.  

                "Minus one vote for the Democrat" equals "plus one vote for the Republican." Arithmetic doesn't care about your feelings.

                by G2geek on Fri Nov 25, 2011 at 09:00:08 PM PST

                [ Parent ]

                •  the ACA invites you to start your (0+ / 0-)

                  own member owned cooperatives. Look up the provisions. if you provide the same benefits you will be able to sell on the exchange and get the federal subsidies for every policy you have.

                  So, look it up, learn what you need to do and do it.

                  You also need to learn some Shakespeare. It the play you quote from the protagonists are discussing what to do when they have sneakily taken over the British crown. They want to get rid of all the lawyers because they represent the justice system and would foil their scheme.

                  I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

                  by samddobermann on Sun Nov 27, 2011 at 07:16:59 AM PST

                  [ Parent ]

            •  oh, please! (0+ / 0-)
              If the Supreme Court endorses it, government will gain it as a generalized power.

              Shit even the first amendment doesn't cover all kinds of speech. Even it isn't  generalizable! You can't yell fire...you can't use profanity on TV before 10 pm, you can't publish child porn. etc.

              You are committing so many logical fallacies it is not worth trying to untangle them.

              I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

              by samddobermann on Fri Nov 25, 2011 at 05:35:48 AM PST

              [ Parent ]

            •  wish i had caught this... (1+ / 0-)
              Recommended by:
              G2geek

              ... earlier. I would've gladly recommended it. Thanks!

              Hyperbole will be the death of us all!

              by MrHinkyDink on Fri Nov 25, 2011 at 08:36:52 PM PST

              [ Parent ]

    •  No. The insurance companies will actually have (32+ / 0-)

      to pay out money when their subscribers get sick, they will not have the "pre-existing conditions" BS. People will be mandated to get insurance, but there will be subsidies to make the insurance affordable.

      Also, it explicitly allows states to start their own 'Romneycares' which can lead to single payer faster.

      Either you are trying to be funny, or you are just spouting right wing talking points out of boredom. Go see a movie or something.

      He's a walking contradiction, partly truth and partly fiction. Kris Kristofferson

      by glorificus on Thu Nov 24, 2011 at 01:15:44 PM PST

      [ Parent ]

    •  Personally I don't think so (14+ / 0-)

      I see it as accelerating many of its worst tendencies. Before too many years hardly anyone will be able to afford medical care. The system will collapse under its own weight.

      I think the wave of the future will be doctors who accept cash, checks, or credit cards. No insurance accepted.

    •  Is this a refutation or a supporting comment? (0+ / 0-)

      Those who forget the pasta are doomed to reheat it.

      by CarolinNJ on Fri Nov 25, 2011 at 01:12:03 AM PST

      [ Parent ]

      •  A little of both (0+ / 0-)

        The author appears to be supporting Obamacare in deflecting from it the blame for the ongoing closing of small practices. I'm saying that yes, it was ongoing before Obamacare, but by making health insurance companies even more central to the health care industry, Obamacare is accelerating the difficulties faced by small practices.

  •  Ditto (50+ / 0-)

    As someone who practiced before there was such a thing as managed care, I second that the Taibbi description is apt.

    Back in the late 80's, managed care got shoved through past regulation barriers in response to the insurance companies whinging relentlessly about their costs. Actually, medical folklore has it that they had to get a specific exclusion to racketeering laws in order for it to be made legal.

    My charge for an office visit in 1992 was $45, which I was paid usually 80% of by the IC with ZERO fuss and paperwork.

    Today, in 2011, my charge is still $45, but it's now regularly described as "excessive" by payers and for which I end up, on average, receiving $17 after horrendous deductibles and co-pays that escalate year after year-for the very folks who are paying $1200 a month RIGHT NOW yet are worried HCR is going to be too expensive, by the way.

    Yet IC's continue to whinge to whoever will listen about their "costs."

    Duplicitous bastards and blackhearts, the lot of them.  

    [/rant]  

       

    What's next for the Republicans? Tying Nell to the railroad tracks?

    by Heller Highwater on Thu Nov 24, 2011 at 12:59:34 PM PST

    •  Politicians are useless (10+ / 0-)

      I keep thinking if we really wanted to solve the health care crisis, we'd have put a bunch of doctors and hospital administrators in a room AMD told them to figure out something that works.  The sausage that came out of the Senate is all about keeping the bucks flowing to big companies and little politicians, and is not really designed to do much for ordinary people.

      Frankly, I blame everything on Nixon.

      by J Orygun on Thu Nov 24, 2011 at 03:45:46 PM PST

      [ Parent ]

    •  Doctors need to organize. You (0+ / 0-)

      need to organize and tell the insurance companies to shove it.

      Sitting around whining isn't going to help.

      Call up the SEIU or the AFL-CIO and see if they will help.

      I doubt it will happen. Most doctors are too arrogant. So you sit and stew in your own juices.

      Meanwhile the Specialties make out like bandits and run the costs up and give worse and worse care and some litterally scare the patients to make them keep coming to them.

      I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

      by samddobermann on Fri Nov 25, 2011 at 06:14:27 AM PST

      [ Parent ]

  •  Also, too (23+ / 0-)

    Obamacare will not hurt small business.  The current cost of insurance for small businesses is killing them and preventing them from ever being created.

    “Never argue with an idiot. He’ll bring you down to his level and then beat you with experience.”

    by MadRuth on Thu Nov 24, 2011 at 01:06:39 PM PST

    •  There are subsidies for small (0+ / 0-)

      businesses who provide insurance to their employees and there should be cooperatives to help them buy it more cheaply.

      Prices are starting to come down. They really are.

      I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

      by samddobermann on Fri Nov 25, 2011 at 06:16:13 AM PST

      [ Parent ]

  •  Have to agree altogether (30+ / 0-)

    I entered the health care field right as "managed care" was in ascendancy.  My instructors were completely unable to prepare our graduating professionals for the bizarre economic playing field in which we landed.  The promise of managed care was that redundancy and waste would be reduced.  Instead, the result has been that insurance companies have continued to prosper and increase revenues while the actual care providers have seen revenues and salaries stagnate or drop in most areas of care.  This particular distortion will surely be discussed in history texts as another reflection of the systemic problems that are a part of corporatist capitalism without any semblance of rational checks and balances.

    •  A friend of mine ended his practice (19+ / 0-)

      about six years ago. He was a family physician who had been in practice sine the mid 80's. He finally reached the point where he could no longer take the insurance industry mandating how long he could spend with a patient (no more than 6 minutes! per), paying him less and less as their rates went up and up. He was finally reduced to the point where his costs were simply more than he could expect to be paid by the IC. And his malpractice insurance costs were a big part of that cost, so the ICs had him coming and going.

      It's all but impossible for a doctor to make a living in America. But the insurance fat cats are doing just fine. Wonder why that is?

      •  If there are no doctors, there will be no need for (7+ / 0-)

        insurance companies.

        Of course there will be no medical care, either.

        Progressives will win when we convince a majority that they, too, are Progressive.

        by auapplemac on Thu Nov 24, 2011 at 02:43:38 PM PST

        [ Parent ]

      •  Your friend whines too much, this doc says (31+ / 0-)

        I've been practicing family medicine for about 25 years, and certainly insurers are ghastly to work with. But not for one instant do they "mandate how long we can spend with a patient". Sure, if you want to get rich you have to crank 'em through every 6 minutes and then charge for a 20 minute consult. But I don't practice like that.

        Is it harder to make money now as a family doc than it was 25 years ago? Sure. But we're not starving. I feel a hell of a lot sorrier for my patients with crappy high deductible insurance who have to save up for three months before they can afford a chest x-ray. Or those with no insurance at all who are bankrupted by a three day hospital stay. I can still afford to send my kids to college. Most of my patients can't.

        Now, if you want to talk about how the gross disparity in income between family docs and (say) radiologists or thoracic surgeons is wiping out primary care in America, I'm right there with you. This is causing costs to explode even as quality falls, and no one is talking about it.

        •  Why does the system seem to be geared toward (2+ / 0-)
          Recommended by:
          akeitz, flowerfarmer

          specialists?

          •  It's an artifact of Medicare's opening years. (5+ / 0-)
            Recommended by:
            CarolinNJ, akeitz, kareylou, glynis, Shaviv

            When Medicare was established, to get it past physician lobbies and the AMA, the fee schedule was based on "usual and customary charges" for things like office visits and appendectomies. At the time the fee for a routine primary care office visit was a pittance because circa 1965 most folks were paying it out of pocket. The fees for surgical procedures or interpreting x-rays were much, much higher because such things were much less common and they were often reimbursed by existing insurance like Blue Cross/Blue Shield plans.

            When Medicare got rolling, private insurers quickly followed their lead on fee schedules. The huge disparity beween primary and specialty care was quickly set in stone, and since that time subspecialists have become extremely skilled at gaming the system to expand their income further. There have been several rounds of attempts at redressing the disparity. But every time, when the smoke clears, the primary care/specialty care pay gap is even larger than ever.

            •  It's also a supply and demand issue... (1+ / 0-)
              Recommended by:
              kareylou

              ...in many parts of the country, there's only 1-2 ortho practices, 1-2 anesthesiology practices, etc.  When the insurer has to negotiate a rate, the practice has a monopoly.

              Not so with primary care, internists and pediatricians.

              The big exception to that rule is psychiatrists, who don't get paid anywhere near other specialists although they, too, are scarce.  The difference is that psychiatrists are the only specialists who exclusively sell time, not procedures....and every first year medical student knows you can't get rich selling time.

              And Ralphdog is right:  Medicare rates run the table for all the other insurers and, unless the disparity is solved there, it's not going to change.

              •  Not quite true. Primary care is 'aging out' as... (1+ / 0-)
                Recommended by:
                kareylou

                thousands of primary care docs who entered practice in the more idealistic 1970s die or retire. Consequently in most parts of the country it's much easier to find an orthopedic surgeon willing to replace your hip than it is to find a family doctor who is accepting new patients.

                Ironically this is helping the bottom line of highly paid subspecialists, because plenty of cardiologists and rheumatologists are now essentially practicing primary care for their patients who can't find a family doc. Unfortunately subspecialists provide far more expensive primary care- not just because they charge a lot more, but because they invariably do far more labs and x-rays, since as expert/subspecialists they're afraid they'll be crucified if they miss something. Candidly they also lack the skillset to practice cost effective primary care. But until we effectively address the grotesque primary care/specialty care pay disparity, the lack of primary care will only worsen.

          •  because they are con men. (0+ / 0-)

            they push over treatment. The more procedures they rack up the more bucks.

            And patients trust their doctors too much. They don't question, research. seek second opinions effectively. Too many think more care is better care when it just endanger them more.

            Doctors love to go in to specialties because they can make big bucks. So when they can they push it to the max. After all they deserve it.

            I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

            by samddobermann on Fri Nov 25, 2011 at 06:27:23 AM PST

            [ Parent ]

            •  A friend's uncle, a family doc in New England (1+ / 0-)
              Recommended by:
              kareylou

              with a private practice, opted out of all HMO backed insurance and runs his practice by subscription.

              I believe the fee for each adult was 1,200. and that covered all office visits and some lab work, which could be done in the office.
              I am imagining that his patients also carried catastrophic coverage.

              Currently, i have no coverage and need some, for rheumatoid arthritis, and would be thrilled to pay a good doc directly for quality care- may all insurance companies die a painful death.

              It will be up to the medical community, much as it up to the OCCUPY heroes, to take a stand and just opt out.

              A major hospital in Tucson made this move, a few years ago- could not find a link.

              •  Yeah. Concierge medicine. It's a moral atrocity. (0+ / 0-)

                Physician training in medical school and residency is very heavily subsidized by taxpayers, probably to the tune of 60-70% or more. So when a doctor whose training was subsidized by taxpayers takes his practice 'private', he is taking a publically financed resource out of circulation and using it to benefit only those with the money to pay his monthly fee.

                I believe strongly that it's unconscionable.

      •  Many doctors are making out just fine. (0+ / 0-)

        Study what is wrong with the system. I recommend Atul Gawande's articles. Go to the New Yorker and search on Gawande.

        I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

        by samddobermann on Fri Nov 25, 2011 at 06:22:43 AM PST

        [ Parent ]

    •  Just want to point out that the stagnation and (3+ / 0-)
      Recommended by:
      splashy, ozsea1, Creosote

      drop in wages started in the mid seventies for those of us elsewhere employed.  I can tell you from hard, hard experience, you ain't seen nothing yet.

      Those who forget the pasta are doomed to reheat it.

      by CarolinNJ on Fri Nov 25, 2011 at 01:28:40 AM PST

      [ Parent ]

    •  You are obviously in primary care. (1+ / 0-)
      Recommended by:
      akeitz

      Now if you were an orthopedist or a gynecologist or a radiologist or specialty surgeon or opthamologist your income has been increasing significantly. And if you are the for profit owner of nursing homes or the consultant doctor for one or more you would be far into the top 1%.

      Don't cry and moan; organize and make them stop.

      I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

      by samddobermann on Fri Nov 25, 2011 at 06:20:46 AM PST

      [ Parent ]

  •  Consider sending this to Forbes as a letter (21+ / 0-)

    Most magazines publish letters that comment on content. Also if the web version allows comments, put it there as well.

    Graham is essentially pushing a conservative talking point. Like  other conservative talking points, it is short on substance and long on dervish spin. You demolish the idea and highlight the need to get the health insurance industry out of the delivery system. Insurance should be elective items rather than basic primary care.

    Be radical in your compassion.

    by DWG on Thu Nov 24, 2011 at 02:11:35 PM PST

  •  Strictly as a Patient, Bullshit, This Has Already (12+ / 0-)

    been going on for decades.

    Everything about a healthy economy collapses under Reaganomics.

    Everything.

    We are called to speak for the weak, for the voiceless, for victims of our nation and for those it calls enemy.... --ML King "Beyond Vietnam"

    by Gooserock on Thu Nov 24, 2011 at 02:31:42 PM PST

  •  i've been looking for the link (1+ / 0-)
    Recommended by:
    jgilhousen

    to what Graham wrote --- i can't find it.  

    i'd love to see it and the comments there>

    thanks!

    Faux News ruined my state

    by sc kitty on Thu Nov 24, 2011 at 03:20:00 PM PST

  •  I could not find ... (1+ / 0-)
    Recommended by:
    james321

    ... the article either.  The Forbes site acts rather hinky for me.  Google found another article by him but not this one. Anyone with suggestions?

  •  Only in USA, could an insurance exec make more (15+ / 0-)

    money than a lifesaving doctor.

    What a fucked up health "system"...

    •  keyword search "flea anemia." n/t (0+ / 0-)

      "Minus one vote for the Democrat" equals "plus one vote for the Republican." Arithmetic doesn't care about your feelings.

      by G2geek on Thu Nov 24, 2011 at 05:34:08 PM PST

      [ Parent ]

      •  wait, what? (0+ / 0-)

        spot on.

        The money power of the country will endeavor to prolong its reign by working on the prejudices of the people until all wealth is aggregated in a few hands and the republic is destroyed. ~ Abraham Lincoln

        by ozsea1 on Fri Nov 25, 2011 at 03:00:09 AM PST

        [ Parent ]

    •  Plenty of doctors making a (0+ / 0-)

      million from their practices plus more in their other financial interests.

      They aren't in primary care.

      I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

      by samddobermann on Fri Nov 25, 2011 at 06:30:55 AM PST

      [ Parent ]

  •  My friend, who's an interventional cardiologist, (5+ / 0-)

    is being reimbursed at minimum 20% less what what he used to be reimbursed for the procedures he performs.

    He's in a group practice, which has now gone "boutique."

    We delivered. They failed us. We have moved on. (h/t to my good friend)

    by gooderservice on Thu Nov 24, 2011 at 04:07:46 PM PST

  •  Health "insurance" companies serve (11+ / 0-)

    no value or purpose in a civil society.  They should be outlawed, starting NOW.

    We delivered. They failed us. We have moved on. (h/t to my good friend)

    by gooderservice on Thu Nov 24, 2011 at 04:08:53 PM PST

  •  My doctor is quitting next month (8+ / 0-)

    Says he can no longer afford his solo practice. Going to leave, travel for a while, and take long hikes in the Sierras. He is burned out and disillusioned, and is no doubt the most honest physician I have ever known.

    He did not overbook - respected his patient's time and in turn expected us to be on time. He had a "less is more" attitude about health care, didn't send out for a multitude of tests, never rushed to prescribe meds unless you demanded them, and you never saw a pharmaceutical salesman come to visit - thus no free samples.

    He is a very disillusioned Democrat, thoughtful and soft spoken. He has diagnosed conditions in me that other doctors couldn't, but on the other hand he has also adopted a "let's wait and see if it grows some more" attitude when it wasn't appropriate. I think there is no perfect doctor out there, but I am going to definitely miss this one.

    Oh, and I was surprised to find that he didn't take Medicare patients, altho he made an exception for me when I became Medicare-coverable since I had been with him for so long. I don't know why he avoided Medicare but have to assume it was unaffordable for him to work with them.

  •  This diary (7+ / 0-)

    should be published in Forbes magazine. At a minimum, you shouls send it to Forbes as a letter to the editor and hope they publish it.

  •  Sorry Folks The links are on my blog (1+ / 0-)
    Recommended by:
    jgilhousen

    http://bit.ly/...

    John R. Graham: Obamacare will not kill small practices...they will be dead already!

    "The illiterate of the 21st century will not be those who cannot read and write, but those who cannot learn, unlearn, and relearn." ~ Alvin Toffler

    by gkfahnbulleh on Thu Nov 24, 2011 at 05:24:33 PM PST

  •  I can say sooo much about this subject. (18+ / 0-)

    We have succeeded in America in creating a system that provides the exact opposite incentives to those that a rational system would provide.
    First, our fee-for-service medicine to begin with creates an incentive to providers to cheat the system.  Only a few do, but we then create a massive system of checks to catch and prevent cheating.  Much of medical documentation actually has nothing to do with patient care.  It's all for one purpose: proving that you actually did what you are billing for.  
    Then, we have the bizarre intersection of expensive medical education and a system that vastly underrewards primary care and relatively overrewards specialty care and procedures.  Docs come out of school with a quarter-million in student loans.  They look at what primary care pays and they can't afford it.  So they go into a procedure based specialty.  And when you have more specialists and fewer primary care docs, you will most surely get more of what specialists do: expensive tests and procedures.  So we have a system that costs to much and delivers too little.
    And now, the confluence of primary care docs fed up with the insurance maze and too short on money with the advent of the hospitalist system.  The result is more and more leaving their practice to become hospitalists, working on salary, free of the business of medicine - but with primary loyalty to the hospital, not to the patient.
    We need two fixes: single payer, of course, as any rational person knows, and free to cheap medical education.  Medical school should be hard to get into, challenging to complete - and free.  That way you'd get the best doctors with a passion for what they do and increase the pool of primary care, which is the best bargain in health care.

    "Wouldn't you rather vote for what you want and not get it than vote for what you don't want - and get it?" Eugene Debs. "Le courage, c'est de chercher la verite et de la dire" Jean Jaures

    by Chico David RN on Thu Nov 24, 2011 at 05:42:59 PM PST

    •  Thank you for this comment. As a patient, (3+ / 0-)
      Recommended by:
      Creosote, kareylou, Chico David RN

      I worry about going to the doctor. I wonder if the treatment recommended cannot help but be swayed by the factors you outline. I wonder if what happens as a result of my doctor visit will be what is best for me, or what is best for the bottom line.

      I worry that my family practitioner is not being justly compensated for the care he provides. He should be the nexis for all my health care needs, coordinating care of specialists for me to be sure that each knows what the others are doing. I learned of this valuable function for primary care physicians as a military family member.

      Once the "medical profession" became the "health care industry" the American people were in for trouble, because money, not health care, became the bottom line.

      "The object of persecution is persecution. The object of torture is torture. The object of power is power. Now do you begin to understand me?" ~Orwell, "1984"

      by Lily O Lady on Fri Nov 25, 2011 at 03:22:52 AM PST

      [ Parent ]

      •  You have the right idea, Lilly! (1+ / 0-)
        Recommended by:
        Chico David RN

        It is the doctors (not all!) who have become the "health care industry" that is indeed the major problem and the major cost drivers for the systems.

        You have to do your own research — and learn how to discriminate as to what is out there.

        I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

        by samddobermann on Fri Nov 25, 2011 at 06:43:28 AM PST

        [ Parent ]

    •  No you would still get the greedy (0+ / 0-)

      pigs of specialists. They would be even more interest. So you would subsidize those who go into boutique practices or cosmetic surgery or some of the ones that super pay.

      The ACA has provision for loan reimbursement for primary care doctors who go work in underserved areas for 5 years.

      And more medical schools are trying to attract a very diverse class who are likely to return to rural areas, inner cities and other underserved places.

      They are also funding ways to use telemedicine so a rural doc can readily consult with big city specialists when needed.

      And more.

      I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

      by samddobermann on Fri Nov 25, 2011 at 06:40:28 AM PST

      [ Parent ]

      •  If med school was publically funded, (2+ / 0-)
        Recommended by:
        kareylou, Chico David RN

        we could stop the proliferation of those going into exclusively "super pay" (love it!) specialties simply by keeping enrollment to the level deemed reasonable.

        A student who wanted to go into a specialty that wasn't needed could opt to pay for it herself.

        I think in a free market there are some issues with the government totally controlling access and payment for medical school, but it needs to be discussed.  If nothing is done, I fear that we will have plenty of cardiologists and orthopods, and no primary care docs.  

  •  Do small medical practices exist... (2+ / 0-)
    Recommended by:
    ginja, CarolinNJ

    ...in places like England, Norway, France, etc.?  You know...places where they have that horrible socialized medicine?

    •  Most doctors are in private practices (0+ / 0-)

      but there are more limits and oversight.

      Britain has problems with the variability in care quality in different areas of the country. Socialized medicine is not the whole answer.

      I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

      by samddobermann on Fri Nov 25, 2011 at 06:45:26 AM PST

      [ Parent ]

  •  My main compliant (1+ / 0-)
    Recommended by:
    CarolinNJ

    with "Obamacare" is that it does nothing much to blunt the ever rising cost curve for middle class Americans. So the Obama deal may have not contributed to destroying small practices--but given the chance he sure didn't help them much either.

    But I guess when you get those same overpaid, blood sucking CEO's to write much of your healthcare legislation you can't be too surprised at the end results.

    To use a Matt Taibbi description: The health insurance industry is a giant vampire squid wrapped around the heart of the American health care system, relentlessly jamming its blood funnel into anything that smells like money.

    With his mandate and his refusal to attempt any real, serious change to the prevailing system, Obama did the for profit healthcare insurers proud.

    •  One. It does have major provisions (0+ / 0-)

      that WILL bend the curve of health CARE costs down. "Bend" because we can't TELL the doctors and hospitals what to do. This is America. We are all, each of us, captains of our fate. It really is hard to change  the system but there are lots of things that will push for real change.

      You look at just a little superficial part, basically it's paying for it. The major problems are in the care itself.

      So here's the thing. Obama did try, he got passed, the law that WILL produce real, serious change. You just don't know enough to look and see it.

      You haven't looked at the bill. You can read just the section titles to learn a lot about what is in it from them. There is even loan repay for primary care doctors and dentists. There are Community Health Centers, about 1500 of them.

      These things alone would reduce costs.

      But just make statements that aren't true. Contribute to the bad polling on this issue. Don't worry about how that can hurt Democratic candidates and aids the Repubs.

      Oh by the way, Krugman has finally caught on that the ACA does a lot to reduce the actual costs for Medicare for the federal budget. He actually used that in an argument with a conservative as the Democrats solution to cutting Medicare which the Republicans are screaming about.

      I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

      by samddobermann on Fri Nov 25, 2011 at 06:58:39 AM PST

      [ Parent ]

      •  I know enough to know (0+ / 0-)
        So here's the thing. Obama did try, he got passed, the law that WILL produce real, serious change. You just don't know enough to look and see it.

        I can see no end in sight to the premium and deductible cost raises in my work based health insurance. And it has only sky rocketed further since this Obama debacle.

        So your wasting your time trying to convince me. This crap of telling people enough times that it is a good thing eventually they will believe you (even when the the opposite is more the obvious) only works for the Republicans with their type of base--not for a Dem who votes on actually results achieved---NOT WISHES, OR HOPES.

      •  the real reason for "Obamacare" (0+ / 0-)

        to me appears to be a staged plan to take off the federal government and put onto the backs of the middle class the cost of insuring the indigent and working poor.

        Why do I say this? Because the government accounting office has said as much that the passage of "Obamacare" would ease the burden on the government and thus help to reduce future deficits.

        Now a lot of us working people at smaller companies are likely to see our company health based insurance disappear altogether--That is the threathened reponse to "Obamacare" from a great number of small companies if they cannot get an exemption (say such as Walmart, and McDonalds reportely did).

        The smaller companies will find it cheaper just to pay the per worker fine. Now all the cost of having health insurance will be on their employees backs and if the employee isn't of sufficiently low income he will not get any help with these costs from the government. The end result will be him shouldering much greater costs than he ever had to before. So the individual either shoulders these high extra costs or he pays an extra tax to the IRA if he chooses to go without an insurance plan. All this money from the fines and taxes and/or the extra costs that an individual now picks up paying for his own health care helps to cover costs to insure those deemed income sufficient enough to get much , if not all of their costs payed for. But not paid from general federal funds, but rather payed for from us through the fines,taxes,etc.

  •  Docs are not the 1% (0+ / 0-)

    for the most part.  They're usually upper middle class, like many of us.

    Health workers of all kinds are one of our biggest ally groups.

    'You want a job, don't you?' - Herman "Koch" Cain, "The Audacity of Grope"

    by thenekkidtruth on Fri Nov 25, 2011 at 02:15:42 AM PST

    •  Many are. Most specialties members are (0+ / 0-)

      in the top 1%.Some even earn more than a million from their practices. That is after expenses including malpractice insurance.

      The critical problem is better compensation and more adequate time for patient care. Sometimes other types of staff are very important. There are things happening.

       Read Atul Gawande's New Yorker article about Dr. Brennan.The Hot Spotters
      Can we lower medical costs by giving the neediest patients better care?
      by Atul Gawande

      Read more http://www.newyorker.com/...

      I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

      by samddobermann on Fri Nov 25, 2011 at 07:14:13 AM PST

      [ Parent ]

  •  Although I had not intimate knowledge of (1+ / 0-)
    Recommended by:
    glorificus

    this, I'd already figured it out years ago. I'd decided that the American health care system would be better off if we did away with all health insurance, since then any money spent would go to acutal health care providers.

    Better yet, though would be single payer heatlh insurance--Medicare for All.

    "The object of persecution is persecution. The object of torture is torture. The object of power is power. Now do you begin to understand me?" ~Orwell, "1984"

    by Lily O Lady on Fri Nov 25, 2011 at 03:13:09 AM PST

    •  Lily, Medicare is sinking fast. (0+ / 0-)

      That's why most of this bill is about Medicare and the other important facets of the HC system.

      The insurance parts are all in Title I. There are ten titles.

      Go to Thomas  I don't have the cite now. Google the PPACA and look for the Thomas site.

      g'night. i swore I was going to bed early. Fail again.

      I'm asking you to believe. Not in my ability to bring about real change in Washington ... *I'm asking you to believe in yours.* Barack Obama

      by samddobermann on Fri Nov 25, 2011 at 07:17:45 AM PST

      [ Parent ]

  •  While some have called it cherry-picking (2+ / 0-)
    Recommended by:
    flowerfarmer, glorificus

    this outfit, which started in Seattle a few years ago with the slogan that they did not require and would not accept any insurance, not even Medicare, at least seems to give relatively healthy people a decent chance to pay $500-$1000 a year and get some decent treatment, and I assume trustworthy referrals.

    It is a pay as you go system, much like what was common in the 1940s-'50s.

    I'm planning to investigate it next year.

    Their figures on time spent on insurance paperwork are consistent with yours.

  •  If I can go in and reception can tell me straight (2+ / 0-)
    Recommended by:
    Jagger, glorificus

    up what a thing is going to cost we're on the same  side. When I get evasive answers because the "provider" is charging different rates for different people and the highest for the uninsured.... I have little empathy.

    "Slip now and you'll fall the rest of your life" Derek Hersey 1957-1993

    by ban nock on Fri Nov 25, 2011 at 06:00:20 AM PST

  •  What this diary is about (0+ / 0-)

    to me, is the ability of the MSM participants to position bullshit as gospel. If this Forbes writer was a real journalist, he would have provided a voice for someone like this diarist to counterbalance the anti-Obama slant.

    Too bad so many other comments on this thread revolve around criticism and support of Obama's healthcare plan.

    -7.5 -7.28, I refuse to believe corporations are people until Texas executes one.

    by Blueslide on Fri Nov 25, 2011 at 06:44:54 AM PST

  •  BCBS (0+ / 0-)

    Every six months or so, and more often if there's a claim for more than a few bucks, they send me a form inquiring about any other health plan I might be covered by, supposedly to coordinate benefits. Until they receive my reply, they hold off on paying the provider(s) for their claim(s).

    Yeah...

    "A lie is not the other side of a story; it's just a lie."

    by happy camper on Fri Nov 25, 2011 at 06:50:54 AM PST

  •  This is exactly (0+ / 0-)

    why my dad didn't urge any of his children to go into medicine. His small pediatric practice was practically destroyed 25ish years ago when he had to hire a full time employee to handle insurance claims. Then he sold to a hospital 6 months before he died - and they told him what he had to bill his patients - more than he wanted or needed because that's what the insurance would reimburse. All he loved was taking care of babies, which is what it should have been all about.

  •  Diary is mostly BS (1+ / 0-)
    Recommended by:
    glorificus

    Heath care is better now than it's been for a long time. Obamacare is a huge step in the right direction.

    It's true that it's too expensive and that some of that cost is due to insurance companies and their methodology. There's not an easy way out of that, not at least until we can get a SCOTUS that will let us institute campaign finance reform.

    Meanwhile:
    1) HMOs and hospitals are not inclined to buy up failing practices unless they can fix them. Why buy a failing practice, unless the reason is that the folks running them now can't, and another manager could? IOW, manage a practice as well as an HMO, not a very high bar, and it will do fine.

    2) My primary care is through a small practice. They are doing fine, even though they include obstetrical care in their practice. Perhaps they do fine because they include obstetrical care and all other care, just like primary care doctors are supposed to? Or perhaps it's because they run their practice using the new digital tools, are smart, and hire good help? They aren't getting rich, but they have a higher income than I do, that's for sure.

    The wife of a small practice doctor was complaining to me, saying that "The money isn't what we thought it would be." They own a nice waterfront home near the practice, and another home in the southwest. They vacation where they want and play golf with a passion. They're not living in a box.

    Health care in this country isn't perfect, but it's not perfect anywhere else, either. We've made huge strides in the past 3 years and we will make more progress in the next 5. We need to get more dinosaurs out of office and bring in more intelligent people. Heath care is a political football in any country where there is a governmental component to it. No way out of that.

    Single payer isn't a panacea, either. Then when Republicans have a majority, they would completely control your health care. What a pleasant prospect, eh?

    Corruption is what keeps us safe and warm. Corruption is why we win. -Syriana

    by CarbonFiberBoy on Fri Nov 25, 2011 at 08:07:26 AM PST

  •  Have we now agreed (0+ / 0-)

    that it is properly called "ObamaCare"? Should we just give up and start referring to the Democrat Party?

    To keep our faces turned toward change, and behave as free spirits in the presence of fate, that is strength undefeatable--Helen Keller

    by kareylou on Fri Nov 25, 2011 at 08:34:02 AM PST

  •  The main reason for "Obamacare" (0+ / 0-)

    to me appears to be a staged plan to take off the federal government and put onto the backs of the middle class the cost of insuring the indigent and working poor.

    Why do I say this? Because the government accounting office has said as much that the passage of "Obamacare" would ease the burden on the government and thus help to reduce future deficits.

    Now a lot of us working people at smaller companies are likely to see our company health based insurance disappear altogether--That is the threathened reponse to "Obamacare" from a great number of small companies if they cannot get an exemption (say such as Walmart, and McDonalds reportely did).

    The smaller companies will find it cheaper just to pay the per worker fine. Now all the cost of having health insurance will be on their employees backs and if the employee isn't of sufficiently low income he will not get any help with these costs from the government. The end result will be him shouldering much greater costs than he ever had to before. So the individual either shoulders these high extra costs or he pays an extra tax to the IRA if he chooses to go without an insurance plan. All this money from the fines and taxes and/or the extra costs that an individual now picks up paying for his own health care helps to cover costs to insure those deemed income sufficient enough to get much , if not all of their costs payed for. But not paid from general federal funds, but rather payed for from us through the fines,taxes,etc.

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