In preparation for my 7 blogiversary (5/19/2002), I will run some of my original posts. This is the first post ever!
Increasingly physicians are closing their practices to new Medicare patients. We physicians can provide better longevity and quality of life for those over 65, but we can’t afford to see the patients. The economics are simple. The reimbursement for a patient visit are less than the corresponding overhead. Consider this carefully. A Medicare only practice would cause bankruptcy. Thus, frontline physicians will have to limit their Medicare patients. I find this situation difficult to understand completely. The finances of medicine have confounded my understanding since I finished my residency in 1978. Who makes money these days? Clearly the pharmaceutical companies have done very well (a rant on that in the near future). Diagnostic studies seem to do quite well (CT scanners, MRIs, etc.). Surgery makes money for hospitals. Thinking, considering and talking to patients has little apparent value. This is not a new situation, but I believe it has become a critical situation. Patient care becomes more complex every year. We need excellent general internists and subspecialists who can take the time to properly care for patients. But apparently society and the insurance companies don’t value that interaction. We have not made the compelling case that excellent medical care starts with a CAREFUL consideration of the entirety of the patient. Fifteen minutes is not enough. $39 is not enough. How would I write this same post today? As we prepare to address our health care "crisis", we should strongly consider the problem of payment for cognitive services. We have strong data that continuity and cognition matter and lead to improved outcomes with decreased costs (see the ACP primary care paper.) Yet Medicare payment rates for routine office visits have led to many internists putting up "no new Medicare patients" placques in their offices. Patients have difficulty finding good internists in 2009, and the problem has gotten worse since I first wrote about this issue 7 years ago. We will not successfully address health care reform unless we fix the payment system for physicians.
{ 6 comments… read them below or add one }
How much SHOULD a physician earn? If we all agreed on that, then we could just multiply by the number of practicing physicians, and Medicare, and every other insurer, would have a place to start. Now they’d have a fixed cost and could plan accordingly.
Let’s say every doc gets $500,000/year. Let’s say there are 500,000 docs. OK: $250 billion/year. (I do think we should throw in something for the retired curmudgeons such as myself, in recognition of “a life of service.”) No difference regardless of what you practice. You want to do ortho? Fine. Do it because you love it. Neurosurgery? Same. Peds and FP: no longer the red-haired stepchild. Shrinks can re-insufflate. We practice medicine because we want to, because there ain’t nothing better.
No incentive to echo everybody with a beating heart – I’ve known the cardiologist who did. Or do a sleep study on everybody who sleeps. Scope folks at the end of the month when you see you can’t make a mortgage payment – don’t say it doesn’t happen. (It just doesn’t happen where we practice.) No incentive whatsoever to call everybody a Level V. And if you do – if you do anything that is “hateful to you” (I’m looking at the Hillel quote in the right margin) and therefore, by definition, unethical, you are out. No license. No second chance. No trip to the local Betty Ford and a spiritual rebirth. No letter from the highest level cleric you can muster. You’re out. Anybody covers for you – he’s out. You are your brother’s keeper as much as your own.
Who would turn it down? OK: guys in plastics with Park Avenue practices. Don’t need them. The neurosurgeon or orthopod cracking everybody’s neck and back? Don’t want them; they have too much of a problem naming their race horses. We police ourselves.
Now, what would doc’s offer for that? You don’t need the big office staff – you get a pay check. Malpractice insurance? Since we all know what we’re doing, we are all practicing according to the community standard – so maybe no medmal. There might be “bad luck insurance” – a payment to a patient who had the right procedure with a bad result. But that ain’t none of us.
No staff. No medmal. No records: insurers and the Feds actually have the incentive to make sure there are detailed and appropriately documented charts since now THEY have to worry about the efficiencies. Charting goes back to being an art and a science; we’re not padding because they ain’t paying. We do it because it’s the right thing to do, kind of like sculptors respecting granite or poets rolling words around for the taste of their connotations.
Doc’s do public health. Every doc. We go to schools and shuls and churches and mosques and community centers to teach. (After all, “doctor” comes from “docere” – to teach.) We meet with every local mayor, every month. No meeting? You’re out. Yes, you’re always on call unless checked out. Just like Marcus Welby. But now you don’t worry about whether there’s a Good Samaritan law, or what your responsibility is. You are a doctor. You belong to the community. The community belongs to you.
So, DB’s point is well-taken.
But why doesn’t anybody ever ask us what we want, what we’re willing to give?
First post ever could be a monthly repost. Same sh*t, different year. (every 7 years).
It definitely set the tone for your blog. As it should have. Because it’s the main issue at hand for those of us who would like to practice proper medicine.
Keep up the good work.
In my are for 2009, and as published on the web, a 15 minute established Medicare visit if $59.98 for primary care. Medicare currently is one of my top 4 payers in Illinois. The majority of the working class insurance companies are paying 10-20% less than Medicare. Medicare patients are more involved, in that they often have many illnesses, require home health, require medical equipment/durable medical goods, and more frequent admissions than the younger population. Currently Medicare is over half my annual patient visits. My practice could easily survive on just Medicare, and I look forward to taking care of the geriatric patients, who still seem to have respect for their doctor.
I look forward to seeing my patients of all ages, and it is a bonus that Medicare rewards me for my work. Another advantage of Medicare is that the fees are set, and the same contract is available to all primary care physicians in my area. The private plans do a one way negotiation with a take or leave it attitude, which is why many of the private plans do not even meet Medicare fees.
As a side note from above, most doctors, outside of neurosurgeons and orthopedic surgeons do not make $500,000 a year. The average salary for primary care doctors ranges from $140,000 to $185,000, depending on the source. Primary care physicians do it for the love of the one on one care of patients. I don’t think any plan is going to significantly cut specialty physician salaries, as the specialists are known to donate to may PACs.
Medicare and Medicare Supplement Insurance have been the backbone of providing financial security for over forty years. We have to do whatever it takes to keep these programs intact.
solo dr,
I have the same situation. In NY, all the insurance companies pay 20 to 40% less than medicare. They also do one way negotiations. I understand that if you are affiliated with a hospital or a group of 100 or more specialists then you can negotiate a better fee schedule. For us solo’s that are doing the right thing for the patient, the insurance companies don’t care. (I especially have a beef with United Healthcare).
I don’t know what malpractice rates are like in Illinois but we are at 30K for internal here and a job at 100K a year is starting to look good. Especially since the beginning of this year we have seen patients avoid getting care and bringing our patient volume down by 30%.
Malpractice insurance rates for my area of Southern Illinois are Tier 1, high risk counties. I am rural, but I pay the same rates as Cook County, in Chicago. With my 10% discount from never being sued and my 15% CME discount, I pay $33,800 annually to practice family medicine. Without the discounts, my policy lists at $44,800. In my area Beechstreet, GHP, Cigna, and UHC are offering fees that are the less than Medicare’s fee schedule from 3-4 years ago with no annual updates for inflation. Medicare is the only plan that continually provides at least 0.5% to 2% annual update that is equal among the primary care doctors in my region without having to negotiate fees. The other plans have flat lined my fees for 3 years, while my malpractice insurance has doubled. If I didn’t work to keep my overhead low, I wouldn’t be able to practice medicine and provide one on one care to my patients.