“Questions from the panel about Dr. Wood’s model have centered on whether it’s fair to charge patients for services they might never use.”

How is that different than paying for insurance coverage? Up until 2 years ago … I don’t think we used ours more than 3 times in a 16 year period.

I see just as many problems with the “retainer model” as I do with the current model … perhaps even a few more problems. I think it would impact certain specialties in a rather huge way.

Also – I don’t necessarily see doctors gaining time with patients in this way. In order to make enough to cover expenses, they’ll still simply need to add on more patients. Granted, they won’t be seeing each one of them all of the time, but it will increase the numbers they do have to see on an ongoing basis.

I’m not a fan of the concierge model. Delivering more access and more one-on-one service to those who can fork over the extra money is just going to perpetuate the economic and geographic inequities that already exist. Those who could really benefit from the extra service might not be able to afford it, while those who can afford it might not need it. And I don’t see this model flying at all in areas that are already medically underserved – it’s just not a good use of resources.

The retainer model being proposed in W. Va. sounds intriguing, though. It’ll be interesting to see what happens.

Just asking here as a non-physician: How do physicians feel about being salaried? What would happen if you were all salaried instead of being paid according to how many patients you see or how many procedures you do? In other words, make your time and expertise and service more important than throughput. Or would the sky fall in if that happened?

“How do physicians feel about being salaried?”

There are venues for this: closed-panel HMOs like Kaiser-Permanente and the VA, and of course, the military.

I think it can be good and bad. Some salaried jobs are reasonable and some are nightmares. I have heard stories from FPs in the Air Force that are not good: huge and chronically underserved patient panels, woefully inadequate ancillary support and unresponsive and irresponsible management. I have heard in contrast good stories from doctors in the VA. I think it depends on the quality and motivations of the management. As far as I can see, the military has more of a “burn ’em till they blow” philosophy, counting on having mid-level medical officers quit and be replaced by new grads, rather than staying for a full career where they will become eligible for costly retirement benefits.

Some of us don’t want to work for a large employer and don’t want a manager telling us what to do or who to see. I did the military for a while and definitely prefer to be civilian now.

I am a Nurse Practitioner with a rural health family practice clinic in in a small town in Louisisana where good ole boy politics is alive and well. I bought this practice from an elderly physician (this is legal in LA) 4 years ago. He took care of everyone in town along with his dad and grandfather before him. As more doctors moved in, it became a practice for the poor, uneducated, uninsured, medicaid, medicare, some private insurance still came, but you get the picture. The new doctors in the town did not approve of this doc and his way of medicine and underhandedly gave him trouble, despite the fact that most of them had started their business in his very office and when they left, took many of his patients with them and still he flourished. His daughter tried to come in and work with him as a Nurse Practitioner and they gave her so much trouble, she left town.
Thinking that I was born and reared in this small town, taught nursing in the town for over 20 years and worked with everyone of these docs, thought I would be ok buying the elderly doctors practice. We also thought that he would be around for awhile and able to be a collaborative practice doctor (which LA law requires). The local hospital took his hospital privileges away (via the doctors) which broke his spirit and within 6 months, he had a heart attack, went into renal failure and died 6 months after that.
I have continued his and his ancestors legacy by seeing the poor, uninsured, uneducated, etc. and realized if I was going to make it in LA, I would have to become a rural health clinic because medicaids community care requires a clinic with a NP must have a doctor in house for at least 20 hrs a week and I knew that was impossible. There are no healthcare providers in town or parish who take new medicaid adults except my clinic. Yet, the doctors have decided they do not want my clinic to exist and so they blackball be and not one will sign as my collaborative physician. I have to pay exhorbatant fees for out of town docs to serve in that position. None of them want to see my patients whom they say are too “risky”. They ambush me at meetings and try to accuse me of all sorts of things, the last being that of “price gouging” the evacuees from Hurricane Katrina. Never let me say a word in defense, but I saw 150 of those evacuees, gave almost 50 blood glucose monitors away as well as emptied my sample drug closet and never made a dime and FEMA who had promised to pay us something, called to say we’d not get any payment. Most of my patients have to walk to my office because they have no transportation and my only salvation is that their are some docs such as cardiologists who come to town and see my patients gladly. My visits are the least expensive in town, with my normal visit for cash paying pts being $50 as compared to others who charge $150 – $250 a visit and they are not specialists. I cannot morally or ethically raise my prices to those standards or even close because my patients could not afford it. Plus, I give them samples of meds that last for a month or more to get them through so them can apply for pharm assist. We get 4 and 5 new patients a day, not all indigent, and many who just want someone to listen to them and treat them like people. I learned that with a physical assessment and what the patient tells me, I can learn with almost 95% accuracy what is wrong with them without doing all these unnecessary and expensive tests that they can’t afford or we as tax payors can’t afford.

The doctors are one of the problems we face. Most private insurances will not credential NPs and so if a patient wants to see us, they will either have to pay the price or if the insurance treats it as out of network, 60/40 is the break. Why would they do this when we can give such cost-saving, efficient and effective care? One reason is that most insurances have credentialing boards and on those credentialing boards are doctors who vote to keep NPs off the board and vote to not credential NPs. Why? They see us as moving in on their territory when if they would just think about it, NPs know their limits and will refer as soon as it is obvious the patient needs further treatment beyond their scope of practice. Most of our practices are made up of patients they do not want in their fancy offices with pretty furniture that some dirty patients might ruin. (My furniture is old and plastic). They say we have less education than them – not so for all of us as I have 12 years of nursing education with a dual degree in clinical nurse specialty and nurse practictioner. Even if I did not have that many years, the education is there as is the nursing knowledge which we all possess which helps us through the process as much as the medical knowledge, add in there a little common sense and a healthcare provider you have with all the tools necessary to take care of patients or refer them to someone who can. All the while keeping the costs down.

If all people with private insurance wish to utilize the services of a Nurse Practitioner, they should call their insurances and insist that they credential Nurse Practitioners and then meet with your legislators and explain why you think NPs are the future of healthcare and the sooner they jump on board and change antiquated wording in the laws, the better off everyone will be. We will then have equality in healthcare for all.

Sincerely,
Nina Ravey, RN, MSN, CNS, C-FNP