how bad does it have to gt before PCPs rebel instead of just complaining?
In response to one of many, but most recent, rants about performance measures, a reader wrote the above question. PCPs are rebelling in droves!!!
The primary care rebellion has two major foci:
- Docs leaving outpatient medicine to either retire or become hospitalists
- Docs developing retainer practices
The first is clearly measurable, although I do not know the numbers. This rebellion is palpable and large (anecdotal information).
The second is sneakier. Pauline Chen wrote about this yesterday, but she did not ask the big questions – Can Concierge Medicine for the Few Benefit the Many?
This past weekend I had a wonderful 4 days visiting old friends in Virginia (of course golf, dining and wine were involved). We talked about many issues, but one issue that surprised me was the issue of retainer medicine. This conversation echoed conversations I recently had in Alabama. Internists (and to a slightly lesser extent family physicians) are leaving standard practice in droves, opting instead for retainer style practices.
Many bemoan this move. Read the comments attached to the accompanying discussion piece – Having Your Own Doctor on Call
We should rather work to understand the movement (as I write repeatedly). Retainer medicine succeeds because physicians are happier (even at the same take home salary) and patients are happier (even with paying these fees). Retainer medicine represents a classic economic interaction – I have a service that I can provide at a costs – and you are willing to pay the cost.
Why does retainer medicine exist? The current payment system is so badly broken and comes with so many strings attached that it ruins the joy of practicing medicine. Practicing medicine is difficult but rewarding (emotionally, intellectually and financially). But Medicare and the insurance companies have made outpatient medicine a miserable experience.
If one reads books about management and leadership, one quickly understands the problem. Everyone wants relative autonomy in their workplace. We all hate micromanagers. The insurance companies and Medicare represent micromanagers. Many physicians would work for less money to remove the rules, billing procedures and pre-authorizations from their life.
Physicians like caring for patients; they dislike the paperwork and bureaucratic nonsense that the insurance companies and Medicare have brought to the practice.
Too many critics blame those physicians choosing retainer medicine for decreasing patient access to primary care. Those critics expect anyone who does primary care to sacrifice their happiness and enjoyment of their profession. Many primary care physicians are unhappy because they know that they are providing care that they cannot take pride in – because of the rules!
Unless the wonks and insurance companies wake up, they will find no primary care physicians left to care for the population. And do not tell me that NPs and PAs will pick up the slack – because they will not (that is another very long blog post). Wake up America; Wake up Congress and the White House. The rebellion is underway – it is just a stealth rebellion.
{ 9 comments… read them below or add one }
As I sit at my desk,eating my sack lunch, filling out the multipe DME forms for my medicare patient's wheelchairs, home oxygen, nebulizer equipment and diabetic test strips, the allure of concierge medicine becomes stronger and stronger. I could rebel by refusing to fill out the medicare forms, but then the patient suffers. Hopefully I will have time to get to the drug preauthorizations later!
The level 3 or level 4 visits do not begin to cover all the free work we do. Most practices are close to the breaking point under the poor rewards system. Most visits average slightly more than $50. Why do we stand by and allow Medicare and the insurance companies to dictate rules that change at least annually, if not randomly throughout the year. The purose of prior authorization of drugs and studies is simply to save the insurance companies money while wasting our unpaid time. Patients usually have the option of paying for an MRI/CT/drug them selves, but the current crop of patients has been trained to expect to have it all for the $20 copay. It takes guts to drop the insurance companies and Medicare. Until the majority of the doctors do this, the system will continue to function for the insurance companies and not necessarily in the best interest of the patient.
Other aspects of the rebellion have to do with accepting new patients with certain insurances, or any new patients altogether. The recent SGR fiasco that had physicians see real decreases in Medicare reimbursement for the first time have many PCP's nervous, with some refusing to take any new Medicare patients. Though closing panels is nothing new, as more docs leave practice and go retainer, those docs who do accept insurance will have a much easier time dropping the worst payors.
Another foci of the rebellion which we have both blogged about before is that none of our students are going into primary care. With so many primary care docs leaving medicine or going retainer, and no new primary care docs to replace them, there will be few docs left that take insurance and will accept new patients.
A trend that is developing among all doctors in my area, as my area has high malpractice insurance for all docs, is that the lowest paying insurance plans are dropped. The hospitals still take every single imaginary plan, but then the patients are out of network if they are assigned to a doc on ER call. My county has lost 10 primary care doctors since July, 2010, as other areas have higher salaries, better reimbursement, and lower malpractice insurance.
For 2010, I have followed my colleagues lead and now have my front desk do a phone interview on any potetnial new patient with Medicare or insurance. Any person on chronic narcotics/Benzos or with more than 3-4 chronic illnesses will be turned away. It is not worth the low fees to take the extra time to monitor patients on controlled meds or complicated Medicare patients. I have had med lists of 20-30 meds on new patients, and no office code adequately covers the time spent doing a thorough history and physical on the complictaed patients. Medicare gets suspicious with too manyLevel 5 visits, and the extended visit codes only add about $25 to the visit. That same time can spent seeing 2 new reasonalby healthy patients or 3-4 established patients.
Under current Medicare rules and some insurance plans, a doctor does not have to see new patients who he/she does not feel comfortable seeing, unless the patient has an HMO with your name on the card. If you want to make Medicare and the insurance companies wake up to the primary care plight, how about refusing to see any new Medicare or insurance patients for a month and booking nonurgent patients out a month, until the fees improve.
Independent primary physicians are being forced to become employed cogs in large corporate medical machines. This is not a side-effect, but by design. 'Reformers' would like all physicians to be employed. Sure, this will solve some problems, and will create a host of new ones. To begin, what kind of medical students will the new & improved health care system attract?
You all miss one safety valve, which is foreign medical docotrs who will still come here in droves and assume primary care positions that go unfilled. For all the whining that I constantly see, I see no organized action to confront these issues by primary care docs. Where is the organization that represents our interests? ACP does a reasonable job, but still represents mostly medicine subspecialties that make up an ever greater share of its membership.
For the most part concierge medicine is only for the established docs who have been in practice and for which patients may be willing to pay the extra cost. It will not be easy for unestablished physicians to go this route.
Part of the problem with the preauthoarization trend is that there has been too much willingness to give patients exactly what they want, regardless of whether they need it or not. It is not good practice to irritate your patients by telling them they really don't need that fancy new motortized scooter to get around. So what check do insurers have to make sure that these supplies and devices are truely needed? I hate them as much as the next doc, but failure to limit to what is needed instead of what is wanted (because the goverment pays for it) is what will bleed Medicare to death and eventually lead to severe cutbacks in much needed medical care. Provide a better solution to restraining this overuse instead of complaining about it!
Ultimately, the solution will be for Medicare to pay accountable care organizations a fixed amount and let these organizations constrain the growth of health care inflation by more appropriatly using their resources. It is scary for providers, but I find the current trends of health care expenditure unsustainable and thus an even scarier senario in the long run.
IMGs still have to do US residencies – and that remains a “bottleneck”. IMGs do some primary care, but they often chose other options. Do not believe that this is a viable solution in either the short run or the long run.
rcentor,
US residencies in the US are currently one of the few that go with unfilled positions. This does not seem to present much of a bottleneck if there are open slots, you would have to agree.
I agree that these internal medicine residency graduates can elect to go on to specialty training, but they need to compete for these sought after postitions with US graduates. The competition is not so vicious for doing primary care.
sorry DB. I appreciate the great post, but I still have to ask the question,
how bad does it have to gt before PCPs rebel instead of just complaining?
I agree there is a quiet and SLOW moving rebellion from PCP. but the still relatively little numbers of docs performing direct pay practices is not exactly making headlines.
I agree with the above comment that ask "where are our organizations?" AMA? (LOL)
AAFP (im still loyal to them but they seem terribly naive and pander to the government to much…)
where is the TIDAL WAVE of outrage and outcry that tells the country we should demand better for our patients AND ourselves?
the real problem…. WE LACK LEADERSHIP in our own arena…
with that thought…. I change my question.
When will we see the rise of a leader that physicians can rally behind to advance our cause?
any takers? DB? me personally, am to busy trying to avoid RAC audits and being thrown to thw wolves by my own government.
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