An eloquent explanation of our reimbursement problems

Before we get all sociological on this, let’s consider some history on why procedures are compensated more than “cognitive” services. In the old days, most of what we today call primary care was done by General Practitioners, MDs who did a year of internship after med school and then went into practice. Specialists were MDs who did procedures (surgeons, OBs, etc) or did additional years of medical training as internists, or medical subspecialists). It was agreed that more years of training should result in higher income, and so it was.

A similar situation occurs today. The old GP is now a family physician or internist, with a 3 year residency. Surgeons and medical specialists, who still earn more, train 4 (OBs) to 10 (highly specialized surgeons) years after med school. More training=more money.

Another thing (that I expect to get flamed about): Surgery is harder than “using our heads.” I put “cognitive” in quotes above for a reason: anyone who believes that diagnosing and treating surgical disease does not involve a hell of a lot of thinking is woefully ignorant. Sometimes I even have to think and operate at the same time! I’m not saying that generating an E/M code is easy; I do a lot of office consults myself and I earn every dollar, even on the ones that do not result in surgery. I do think that an hour in the office is generally less stressful and physically difficult than an hour in the OR, and I do expect higher compensation.

But do I get it? Let’s take a “routine” cholecystectomy. If it is really easy, I can get it done in 45-75 minutes, counting from the time I change into scrubs, talk to the patient, wait while the patient is put to sleep, prepped, the equipment is arranged, then the actual procedure which is typically 30-60 minutes. Then a few more minutes writing notes, orders, talking to the family, and dictating the operative note. If all has gone well, I don’t have to do anything else until the next day, when I see the patient on rounds and discharge her. That is another 15-20 minutes. Typically one or two postop visits, and that completes that episode of care.

Depending on the insurer, I will receive $600-900 for that work. That equals, according to my estimates, between $420-700 dollars per hour gross revenue, assuming that there are no actual or perceived postop problems that will lead to additional hospital days or office visits, which are not compensated during the 90 day global period.

What is the rate of gross revenues generation for a well run primary care practice? I suspect that it extends well into the at least the lower part of my $420-700/hr spectrum. You may replay that your office expenses are higher due to increased personnel and space requirements, but I’ll see that and raise you my malpractice premium.

Am I missing something? Aren’t those extra years of training, and additional stress worth something?

The medical profession is the only profession where the insurance companies tell us how much we can charge for a service. It just boggles the mind! You charge 75.00 for a visit and the insurance company says “hmm.. nope.. you’re only going to get paid 30.00 if your lucky!” Meanwhile the interest rates on our student loans are going up and so is the cost of the insurance that screws us around! ARGH!!!

jb…yes I tried to spend time with patients but not too different from my colleagues.
( 6 have quit in our practice area in 2005-2006to become hospitalists..I’m number 6 )

the time primary care spends on doing things to just deal with the insurance related paper work… takes about @30 minutes/day. this cuts into pt visit time. also we are constantly getting hassled by insurance companies. I hate having to explain to some insurance company lacky why I ordered an adensine mibi stress test as opposed to a treadmill mibi test or why i ordered an CT scan instead of an ultrasound…

I have been aidited twice by Medicare…the first audit came because I was off the bellcurve for charging. Despite you being correct @ undercoding 99214′s….any one who codes more than 25% of their visits 99214 risks an audit. Its hard to swallow a 30,000 dollar penalty…so i use 99214 about 15% of the time. i was audited 4 years later (no reason given) on both audits I did fine but this is stressfull to go through.

on top of that there are the frequent phone calls to explain why the script I wrote costs 12.oo more than another script but i still prefer it. ( ie…lopressor has better data for cardiac protection than atenolol)

Routinely I would also have to respond to health insurance company audits explaining why patient X did not have an eye exam or PSA or mammogram..The nurses could do a lot of this work but not all of it. If you ignore the paper work, you get a not so friendly letter demanding the information later on.

If I had less paper crap I could see more people /day but I can tell you for sure when you see an older adults who cannot hear or remember well, it takes a lot of timeto communicate plans. ( inevitably a concerned child would call 3 hours after the visit saying that their parent lost the scripts or did not remember what I or my nurse would say.)

so the bottom line is that although $320 hour billing was reachable on some days, it was the ecxeption not the norm.
generally speaking my hosp rounding started at 7:15 and I went back to the hospital about 6:00pm so most days were 11 hours with a lot of longer days depending on call. ( I do know that 11 hour days for many surgeons would be considered a light day) One day a week i worked half day.

In our area ( Northern New England) primary care internal medicine would average about 130-160,000 pretax income. Those who earned at the high end were able to see 22-24 pts/day in the office. Those in the lower end ( myself) were seeing closer to 17-19/day. again to see 22-24 pateints a day, really means @ 10 minute face time with a patient. That works for pharyngits but not for CHF, Diabetes, and renal insufficiency (considered routine internal medicine)

I am not complaining…i just took a long look at what my skills were and how i was reimbursed and decided for me…primary care was not worth the hassle.

Very sad to see you Doctors whining because you make so little money.
It is rather disgusting to see a M.D. write that the old, and hard of hearing take up so much time or if one can do a cholecystectomy quickly they will make so much profit.
And the majority of doctors today 40 and under have very, very poor assessment skills.
Keep over billing medicare and insurance companies and keep accepting freebies from drug reps aka detail men and don’t try and help get the drug manufacturer to lower medication costs or the FDA to work for consumers instead of the drug companies resulting in lethal side effects.
Then you have a right to COMPLAIN!
It is very obvious what is wrong with the medical profession today.
Greed, ignorance & lack of empathy for your patients!

To MHeilmann and neobes:
I don’t expect you to understand whiny doctors. I am from a working class family and did my time doing manual labor as a young adult ( high school and college). Manual labor is hard work, no doubt, and I am glad God gave me the intellectual abilities to do what I do. But make no mistake, most people who become healers do it FIRST for the right reason- to help their fellow man. Sure there are some bad apples out there. BUT when you give up a more than a decade of your life to pursue medicine ( and it is HARD WORK ), rack up ENORMOUS debts, take on the HUGE responsibilties that go with the title MD, you EXPECT the village to value that commitment and special effort. I could have gone into MANY other careers ( banking, law, engineering, general contractor, sales, etc.) that would have provided me with a generous hourly income, without the slavish hours during residency, the years of sleep deprivation, the missed family events and holidays, the FEAR of constant lawsuits even when you have done nothing wrong, the outrageous demands of insurers in order to get paid ( at a fraction of my fee I might add), and on and on. So, only time will tell if you or the doctors are right. If you are right and we ” progress” to socialized medicine I wonder if we will have the ” best and brightest”, the most dedicated and energetic, to care for you and me in our old age. I know many of my colleagues are advising their children not to pursue medicine, perhaps yours will step up to the plate to provide the skilled, thoughtful, compassionate, timely and inexpensive care that you are in search of. Be careful, you might get what you wish for ( or not).

sorry about the poor grammer- should read he would NOT give bicillin

another finding was that I charge for labs but they were done at the hospital-Idiot, I have to pay the hospital out of my pocket for the labs I order- and what, I should not bill for them?-

PS the insurer was served yesterday for breach of contract