rob_lamberts's blog

My last post on MedPage was also posted on my personal blog.  One of the comments on that blog was:

And how is the current system better for doctors than Europe’s? Why do doctors fight universal care so hard when they get a worse deal from the insurance companies than European doctors get from the governments?

To which I wrote another post, stating

Sure, the system needs changing;  but simply changing who is writing the check will not make things get any more efficient.  It is not those writing the checks that necessarily need changing, it is those cashing them.  Too many people have their finger in the pie that should be shared by doctors and patients. Do I get frustrated?  You bet.

    
But I do still have enough good to give me reason to hang around.

So what is the answer?  Is it socialized medicine or is it "free market?"  A comment on this second post stated:

How about an approach similar to the Netherlands? Everyone is covered, access to specialists is not limited. Apparently there are a limited number of “insurance plans” (vs. the gazillion variations on a theme per company here) offered to all (none of the preexisting
condition and other exclusionary cr@p) by all insurance companies. I suspect their administrative overhead is a lot lower and price transparency far greater than it will ever be here…and everyone is covered

While Kevin MD chimed in:

At the start of next year, the drug companies will no longer be giving pens and pads of paper to doctors.  The rules regarding pharmaceutical sales practices have grown progressively more stringent over the past few years.  The FDA already regulates what the reps say to physicians (they may only assert what is in the PI, or package insert).  Now they will
be very limited on other contact with physicians.

Thank goodness.  Those pens and pads of paper were sending
subliminal messages to me.  I hear them talking to me in my sleep.  I
just have an insatiable need to prescribe unnecessary medications
because of a ballpoint.  It will be good to get out of this marketing
hell these reps have put me in.

Citizens are worried about the influence these companies are having
over us physicians, wondering if their efforts to influence are driving
up the cost of care.  One online petition site states:

Drug marketing is out of control. Help send a message to Congress.
Support the Physician Payments Sunshine Act, which will require drug
companies to publicly report their gifts and payments to doctors.
Drug companies spend at least $25 billion each year marketing to
doctors. We pay for that with every drug we buy. And studies prove that marketing causes doctors to prescribe higher-cost drugs. Some new drugs also have safety risks (like Vioxx). By increasing transparency, the Sunshine Act will help protect patients and help counter the skyrocketing costs of drugs.

Congress is also getting involved:

Politicians are finally hearing the reality of the problems in
medicine.  Some "insiders" have visited various congressmen and folks in CMS who state that their goal is raising the income of primary care doctors.  They understand the fact that costs are much higher if there is a high percent of specialists in relation to primary care doctors. 
The promise is that over the next few years, the income of primary care
physicians will rise through increased Medicare reimbursement. 

So I am told.

My contacts are reliable.

I don't believe them. 

I don't care if I hear it from the head of CMS and both presidential
candidates.  I don't care if I hear it from the guy who personally
authorizes the checks.  We have been waiting so long, only to see
decreased reimbursement for more work. 

As a group, primary care physicians are jaded.  We are used to being
the step-child.  Hospitals build big wings for OB and Cardiology. 
Specialists build fancy office buildings and drive the expensive cars. 
We are used to seeing insurance company profits shoot up while our
income goes down.  We are a name to put on a list for the hospital so
they can get contracts, or a source of ancillary income for hosptials.

What is the job of the PCP?  To serve as a conduit to send patients to
specialists so they can make more money than us.  To avoid expensive
procedures and keep costs down so that the insurance company profits
are higher.  Is that cynical?  Sure it is.  But is it wrong?

The difficult irony is that our patients value us far more than they
value the specialist, hospital, or insurance company.  If it were up to
patients, we would have a higher income than the others.  But it isn't
up to them.  It is up to the politicians and lobyists.  It is up to the
shareholders of the insurance companies.

 I was sitting in a conference recently;  the speaker was talking about the Medical Home and how one practice was getting nearly $150K for  managing a patient population using a new computerized tool.  Sounds good.

During the question and answer period I asked the speaker:  "Shouldn't we
wait until insurance companies are willing to pay for this before adopting it? 
If we start giving this care on our own, what motivation will they have to pay
us for doing it?"

The speaker smiled and agreed that the "market would have to mature" before
this technology could be adopted.  If we do adopt too soon, we run the risk of
giving higher quality for nothing.  We do extra work - above and beyond what we
are doing now - and do so "for the good of the patients."  Yet while the
patients and payers benefit, our hourly rate goes down.

Sad.

Here is a technology that improves care and potentially saves lives, and yet
we are waiting for a good business case to do it.  Only in America.

A physician came up to me after the talk and said, "No matter what happens,
we physicians are going to get screwed."

That is the climate we practice in.  Morale has never been lower among
physicians.  We are all tired of bearing the responsibility for change without
sharing in its fruits.  Any new program that comes along is suspect.  Where's
the catch?  How is this "great new idea" going to lower my bottom line?

Why can't we just get paid for doing a better job?

Let me make this clear:  I do whatever I can to maintain the best quality
care for my patients as is possible.  I am proud of the quality I do.  Our
practice has actually surpassed most reported quality numbers by far.  We do
well despite this climate.  But the rank-and file physician is
frustrating with having to choose between good care and good business. 

I am a primary care physician - in the crosshairs of the mess we call healthcare in the US.  I see about 30 patients per day.  I answer a ton of phone calls, look at labs, x-rays, consults, and fill out forms every day.  If I take time off from work, I am not paid.  I am the source of most of my income.

I bear the weight of the current healthcare crisis, but am to caught up in the mess to have any time or means to do anything about it.  I can't take time away to advocate for myself, nor can most of my colleagues.  Instead, we are represented by academics and other physicians who are conspicuously "out of the trenches."  It is the classic catch-22 - those with the most to lose have the least voice.

But I can blog.

I can say what I think and have others read it.  The voice of the rank-and-file of healthcare is now out there.  Doctors are starting to understand that this new medium gives us access to much larger audiences.  We have a soap box.  We no longer have to get others to advocate for us - we can do it ourselves.

So those who can listen: pay attention to the bloggers.  They are the real voice of healthcare.  The lobbyists and big organizations may think they understand, but most of them don't have to pay rent, support a payroll, and negotiate contracts with insurance companies.  They make their points, advocate for their bosses, and go home without living with the consequences.

We live with the consequences.

Listen to us.

There is much talk about "transparent pricing" in medicine.  It seems that the belief is that we in medicine hide the amount we charge so that we can secretly charge more and make lots of money.  Nothing could be further from the truth.

It is the Stark legislation that makes this the case.  I can't reveal my charges to other doctors or I will be in violation of the law.  Antitrust is the worry here, as we doctors are so well organized that we would inevitably band together and fix prices.  What it does is handcuff the entire system.

The other problem is that I cannot collect from Medicare patients any more than they will pay (aside from the 20% allowed for those without secondary insurance).  We are at the mercy of the fee schedule which is set by the government.

What if I could just bill what I want and then charge the patient the balance?  What would happen if Medicare's contribution was fixed, but my pricing did not need to be fixed?  Here is what I see happening:

1.  I would not be overly tied to what the fee-schedule was.  Medicare could say they pay only $50 for an office visit, and I would charge the difference.  If that number went to $45 for bugetary resons, it would not doom my practice.

2.  I would not worry about losing money on procedures, which is the case now.  If the Medicare cuts had gone through, we would have lost money on several common things we do.

3.  Patients could choose physicians based on both cost and quality.  If I had an especially good reputation in the community, I could charge more.  Patients would know more of what they were paying for.

4.  Physicians would compete based on quality.  If you offer better service and better care, you would want to make that known.  That way you could charge higher for your services if you chose to do so.

5.  Extending this to procedures and tests would cause the quality and service to improve for those as well.