I feel your pain (oops slick willie already said that.)
I admitted that this bill is not perfect. I worry about the nurse practitioner inclusions, but I doubt that many nurse practitioners will choose this career path.
In our ACP discussions we assume 2 things – state law on licensing does matter and few nurse practitioners will want to run a PCMH or be able to meet criteria.
As I have written so many times, we have a perception problem. I suspect that most internists will redefine themselves – to the detriment of patients. I agree that few internal medicine residency graduates will choose primary care until and unless we can label the job as different from primary care.
The angry comments reflect the definitional problem. Physicians conceptualize primary care differently than do politicians. The physicians cannot imagine non-physicians providing the complex, comprehensive care that they provide. Those physicians are correct.
If I still did outpatient medicine, I would gravitate to a retainer practice to distinguish myself. I have no ethical problem with such decision making. Patients need physicians who can spend appropriate time, and in the 2010s I suspect that only retainer practices will easily provide the desired practice style.
All that being said, I do believe that the politicians are missing the boat on primary care because they think they understand and unfortunately they are clueless. Likely, internal medicine will become redefined into retainer outpatient practice, hospitalist practice and subspecialty practice. The days of the outpatient internist or better yet the comprehensive internists are probably already numbered. I agree that this bill may not save the endangered species.
Nonetheless, I do believe we need reform, and find much good in the bill. All bills have lines that I dislike. I might be wrong, but I still believe that the current situation is even worse.
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I want to comment on your statement about retainer outpatient practices. I am one of the few going into outpatient internal medicine, and am definitely leaning toward a private pay model (which includes considering a concierge-type of practice). I don’t really publicize my desire to do this to colleagues and superiors at the hospital, because I know I am likely to be accused of being “all about the money” and/or “not serving a broad enough demographic.” However, in your previous blog about retainer practices, you made a great point: if that is true, why should dermatologists, plastic surgeons, cardiologists, etc. be excluded from criticism?
I am going to have in excess of $200,000 in student loan debt when it is all said and done. I don’t regret my decision to incur such a large amount of debt, because being a general internist is what I have always wanted to do. At the same time, I also don’t feel obligated to practice in a system where I am underpaid. So I’m not. I’ll take care of the people who can pay me out of pocket, and also take on some charity cases here and there as I feel led. I will sleep well knowing I am providing high quality adult medicine to the public.
With regard to retainer care: has anyone realized that there is a finite number of people who could afford to “buy” into a practice and also pay for their regular medical insurance?
I still maintain that doctors need to get the insurance companies out of their practices. Think of all the disadvantages: slow pay, having to hire extra staff, the mind boggling aggravation, etc. The only way this would work would be if doctors abandoned their multi-tier fee schedule and charged reasonable amounts for an office visit. The fees would have to be in the $50-60 range so that people could pay for them out of current income. The insurance companies could lower rates and then concentrate on the big stuff (of course, there would have to be watch dogs to make sure the insurance companies didn’t just keep collecting premiums at today’s current rates).
How many physicians actually collect on those $200 office visits from the self-pay patient? More than once?
What I am suggesting is only a beginning point in what needs to be discussed concerning the unsustainable costs of our medical industry. Doctors do not like discussing any of this with non-medical trained individuals but they are missing out on a lot of very good ideas. This almost xenophobic response is not helping anyone! I hope that we can all work together to remake medicine a once more honorable profession.
For 2009 and secondary to a decreased overhead, I dropped my visit fees to my best PPO rate plus 15%. I find that I have a 50% increase in self paying and satisfied patients. One patient brought me a bill from her previous primary doctor that was three times what the insurance company would charge. Another patient showed me an ophthalmology bill for $1,800 for single cataract surgery that would have been less than $400 for a Medicare patient.
The current system has unrealistic charges and unrealistic payments. The hassle of dealing with insurance companies adds overhead, and I enjoy seeing self paying patients at fair rates. For 2009 copayments are hitting $35, which can end up being 60-70% of the visit’s total allowed fee through insurance. The insurance companies are ripping off the patients and the doctors for outpatient visits.
The problem is that a practice must set it’s prices at a rate higher than their best contract in order to ensure that that they get paid fairly for *ANY* agreed rate.
For example, if your best contract is BCBS at $65 per RVU, it behooves you to set your prices at $85 per RVU. If you inadvertantly bill BCBS your lowest contract rate–say $35 per RVU, they will keep the difference. Good luck trying to get it back when you discover the mistake later. This necessarily results in penalizing the self-pay patients (though most self-pay patients can qualify for discounts if they bargain with the office manager—and almost every self-pay patient does).
If insurance companies will remove the clause from their contracts that stipulates that they get to keep the difference if my billing department inadvertantly bills them less than the agreed amount, then I’ll lower my prices. But, why I should I have to resort to inefficient and poor business practices on their behalf??