It seems that the central question is how much money doctors expect to make.

How is a doctor who sees 15 patients per day giving good care to be able to make as much as the one seeing 60 patients and giving poor care?

If all doctors now seeing 60 patients were to switch to seeing 15 patients, we’d need 4 times as many doctors, and if each is to make the same amount of money as before, the costs of medical care will necessarily quadruple.

The only ways around that are either for fewer patient visits, or for doctors’ income to drop. Is the former acceptable to patients? Is the latter acceptable to the medical profession?

A, but you don’t consider the overhead. The doctor spends about 55-60% on overhead. It’s not going to cost more, since the overhead will drop and the doctor will do more (even billing, for example, or answering phone messages in person, or using e-mail, internet for scheduling appointments). Also, the office space you need is smaller, why would you need 3 exam rooms if you have enough time to clean the previous one. So, you will need smaller space. Also, you will write better prescriptions, will have time to check if a medication is too expensive for your patient, for example. You will order less tests, because you will be less insecure about your patient’s problems and physical exam. I’ll give you an example : if you have to “squeeze’ a patient in 10 min. and he needs wax removal, you may just want to refer him to ENT because removing wax can be time consuming. Same thing may happen with a pelvic exam- why bother, when you can order a STAT ultrasound. I know it sounds like lousy medicine (it IS lousy medicine) but if all your scheduler gives you for a patient are 10 min, what do you do ?
It’s more complicated than a second grade math problem.

Clearly we cannot afford to continue to give everything to everybody from a medical perspective. My proposal: a 2-tiered system. The basic care would be provided free by the government. Any US citizen could walk into the USCare clinic (possibly pay a nominal fee of $3-5) and get basic care. That includes evaluation, prescriptions (generic only), basic surgery (no hip replacements). Advanced imaging (CT,MRI,PET) strictly limited or not at all. If you have surgery, you will be cared for in an old-fashioned open ward post-op unit, where an RN could directly observe 15-20 patients and supervise a few LPN and techs. No color TV, phone, and private room for USCare patients. Anything else has to be obtained in the private system, where you can pay cash or use your private insurance.

USCare would be financed by dismantling the current government payments for health care. Medicaid and Medicare will be phased out over a decade or so to limit the number of people who paid into Medicare but will not get the benefits. USCare will cost much less, not only because services are limited, but because there will be no lawsuits, and therefore no defensive medicine. No documentation expenses aside from the super-efficient EMR that will give nationwide access to any doc or nurse who is caring for the patient. Docs will happily accept low reimbursement for USCare work because they will be free to practice the way they always wanted. No need to order CYA tests, no need to document 12 bullets to get paid, no fear of career ending lawsuits.

Some might complain that offering less than state of the art care to people is unethical or immoral. Remember that this is not bad care, in fact, it was the care that the high and mighty received 10-20 years ago. Today’s blockbuster Rx is tomorrow’s OTC generic pill (Remember when Tagamet and Motrin were Rx blockbusters?). Those who are still unhappy may contribute to the charity that will be established to provide Lipitor and hip replacements to the indigent. Care will also be advanced because all patients will be enrolled in any clinical trials relevant to their diseases.
This will have benefits for the private medical world also. There will be no cost shifting, so services will be billed to Blue Cross and self-payers for what they cost to provide. Blue Cross will soon learn that the 12 bullet CPT system only raises everyone’s costs, and will be eliminated. The true cost of the current tort system will be apparent, and fixes will be implemented.
The biggest advantage: it will finally shut up those who think that the US is uncivilized for expecting people to pay for their health care. It will also be an ongoing experiment that will challenge high cost interventions to prove themselves. The inevitable huge bureaucracy that will be required to run USCare should not be any worse than the ones we now have to run Medicare and Medicaid.

There is no reason to lament the situation of the doctor fired for not seeing enough patients. It should represent, one way or another, I good experience. If the doctor’s in that practice “needed” to see 60 patients a day, then chances are their overhead was at that level, and too expensive for him. It’s also likely that their system did not account for a doctor with a lower volume having a lower percentage of the overhead (overhead probably distributed evenly). Some overhead works that way, but some is according to the volume of work you do.

On the other hand, the lamentable doctor no doubt needs a lesson in the practicalities of the business of medicine, by being more in touch with the costs of running a practice, and that if you “can only see” 15-20 patients a day, you will only be paid for that many.