As I wrote last Friday, I believe primary care docs are rebelling against the system. The system has made primary care physicians suffer emotionally and financially. The system has taken the greatest form of medical care – that consisting of continuity, comprehensiveness, complexity and completeness – and denigrated it.
Now I talk about "the system" in an anthropomorphic sense, but "the system" is virtual. "The system" has no conscious, it is not deliberate, rather it represents the constellation of ignorance that the insurance companies, CMS and policy works have wrought.
The system has constrained primary care fees while systematically increasing overhead. The system has listened to well meaning researchers and -ologists to declare primary care physicians in need for quality improvement. The system has undervalued the value of a good primary care physician. The system has, without consciously meaning to, held primary care in contempt.
So what do primary care physicians do? They do what any sensible economic citizen would do, they alter the rules to their benefit.
So decreasing numbers of primary care physicians are taking medicare or medicaid. So primary care physicians are leaving their jobs to do hospital medicine. So many primary care physicians are leaving the CMS/insurance company grid and retreating to retainer practices or cash only practices.
The rebellion is a quiet one. No one has declared this rebellion. This rebellion has no Glenn Beck or Sarah Palin; no Abbie Hoffman or Che Guevera. This rebellion occurs one physician at a time, as that physician finds continuing their practice undesirable.
Some believe that NPs and PAs can fill the void, but those who believe it do not understand the complexity of primary care. Retreating from physician led primary care will increase costs by increasing subspecialty referrals. The problem is that too many see primary care as simple, when in fact it is complex.
So I believe the rebellion will continue. Every anecdotal sign that I see tells me that the rebellion is gaining speed and power. Now if Congress is dumb enough to once again fail to fix the SGR, they will encourage more rebellion.
One day the wonks on Capitol Hill will realize the problem. AAFP and ACP (amongst others) have tried explaining the problem to the politicians. Until they understand that their constituents are angry because they cannot find a physician, they will not focus on the problem. The quiet rebellion will eventually stimulate a response. Unfortunately, the fix will cost so much more then than it would have 5 or 10 years ago. Our health care system will be changed, and likely in a very negative way.
And the quiet rebels will not be the ones suffering.
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Hush up already! How can we expect to keep this rebellion nice and quiet if you keep trumpeting our plans to the whole world? Just wait until we all manage to get out safely, before anyone notices and starts trying to tie our hands with ridiculous laws trying to tie licensure to Medicare acceptance, before pointing it out. On second thought, all the pundits and politicians are too busy screaming about non-issues like death panels to notice what's really going on right under their noses. Still, how about we just keep this under wraps for the time being, eh?
I essentially agree with you.
However, I am not certain that internists have made their case as effectively as you have stated.
For example, has anyone compared the hassle factor quantitatively for a complete history and physical exam in comparison to that for an expensive imaging test or subspecialist procedure? The financial return on the imaging test and on the procedure is probably much higher per hassle factor. Second if one is running an overhead of fifty percent on $200,000 gross earnings or $500,000 gross earnings there is a huge difference. The latter may be able to afford more staff to deal with the hassle factor freeing the doctor to do his work or to take time off.
If one is repetitively going through a hassle factor for seeing a patients for $100 visits that has to be repeated several times a day and becomes demoralizing. If one simply goes through that once or twice a day for a procedure that costs $500 that is in effect a much smaller burden.
In addition, internists do essential work. That may sound self serving. I am not certain that other specialties are in that same category to the same degree. I am certified in both internal medicine and in allergy/immunology. In the latter field, I was amazed how people ignored their basic needs to deal with their allergies. I had an intelligent graduate student patient who was having renal colic with severe pain and problems urinating on a more than weekly basis but ignoring that for her seasonal rhinitis which did not seem severe. I was paid much for treating her allergies than for educating her about kidney stones and refering her to a nephrologist for treatment. She had had an ileal resection for IBD. I found that allergists greatly exaggerated the dangers or severity of allergies making my rather conservative approach seem severe.
Perhaps, politicians are more dense than I have give them credit for.
It is sad.
Bohdan A Oryshkevich, MD, MPH
no… trumpet it. say it loud!! we should all say ENOUGH IS ENOUGH!! and start today!
I for one cant stomach another 10yrs this hogwash.
I love my patients but I get a little tired of everyone sobbing over how this or that decision will "hurt patients." (im sure i will get nasty responses about that statement:)
Our patients are not exactly running to our side when they see the governement beating up on PCPs.
the sooner everyone suffers (instead of just PCPs) then the sooner we can fix this mess. cheaper now then later…..
and ultimately it will be better healthcare for all. so all of us need to suck it up and make the scary hard decisions now.
I wish it would be $100/visit. My area average is around $55/outpatient primary care visit including the copay and part from the insurance. The insurance companies and Medicare know the setpoint to keep the docs and patients enslaved to the current system. If copays hit $50, patients are going to think twice about carrying insurance. Around 20% of the patients have deductibles, but the other 80% want the world for the $20-$30 primary care copay. The deductilbe patients, however, are kept on the insurance through other methods.
Deductible patients want the disocutned MRIs/CTs, labs, and meds. Most insurance companies will not allow an out of network doc to prior auth an MRI/CT, and some companies will not allow lab orders to go through without a doc being in network. Meds prior auths also have the doctor's provider number for the insurance on the form. In my area, most HMOs require referrals with authorization numbers to see specialists. You have to be in network to give the referral. My local hospitals for credentialling and recredentialling have questions that include if you are wiling to see Medicare and Medicaid patients.
The only way to not be pawns to the system is for the majority of primary and specialty doctors to quit taking insurance and Medicare. At the same time patients are going to have to stop wasting $10,000 for a family of four for insurance the provides minimal benefits and realize that the majority of the premium is not going toward the care of the patient. The current system benefits the insurance companies and provides little to the patients and the primary care docs.
Good post, but I strongly disagree with the following statement:
"AAFP and ACP (amongst others) have tried explaining the problem to the politicians"
These organizations have done a pathetic job of explaining the problem. They have, instead, taken the very bizarre approach of saying, Yes, the American health care system is messed up, and it's all the fault of our members. They are terrible doctors and their offices are disasters. The only way to imrpove the system is for our members to start doing lots more administrative and bureaucratic chores that no one will pay them to do (i.e., become Patient Centered Medical Homes). All the problems will then disappear. End of discussion.
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