Posts Tagged ‘PCP’

Your government does not like you

November 7, 2009

Well, it certainly seems that way! The people who run Medicare have this brilliant idea to save money: If you are admitted to the hospital with Congestive Heart Failure (CHF), Medicare will not pay if you are readmitted within 30 days.

How mind-numbingly stupid is that? But it gets even better: There is a plan to tax the manufacturers of medical devices. What’s a “medical device”? Oh, things like pacemakers, ICDs, electric wheelchairs…stuff like that. Congress doesn’t see these items medical innovations, they see them as a cash cow. They’re even planning to tax bedpans and tongue depressors.

Nothing in the health care bills address the real problem: The looming shortage of Primary Care Physicians (PCPs). We’re already running short, and an analysis of the plans estimate that PCP workload would increase 29% over the next 15 years… and you thought getting an appointment was difficult now.

Meanwhile, back at the hospital, Cardiologists are facing a cut in Medicare payments. (The actual numbers have just been published.) But before you start thinking we’re finally saving money, think again: The money is just being shifted around. Payments to specialists are being cut, but payments to PCPs are being increased – the pie isn’t any bigger or smaller, it’s just being sliced  differently. The idea is to increase payments to PCPs to help offset their medical school debts. Since Primary Care doctors don’t make as much as specialists, their debt is relatively higher. But the government has managed to mess this plan up, too: PCP payments won’t increase very much.

The PCP shortage is causing doctors to be swamped and patients to be frustrated. The wait times for an appointment are getting longer and longer and there are so many patients that the doctor has less and less time to spend with an individual patient. We’ve all had doctors who seem to walk into the room leaving! Often patients who want to see a doctor ASAP go to the Emergency Room – they are almost as crowded as your “regular” doctor’s office. The EMTALA law (Emergency Medical Treatment and Active Labor Act) says that a patient who presents at an Emergency Department with a medical problem or in labor must be treated, regardless of ability to pay. It was designed to stop patient dumping (and for the most part, it has) but abusers use it as a direct route to a doctor. Since there are no payment provisions in EMTALA, guess who pays the bill of a majority of EMTALA patients? Medicare… in other words, you.

One option that is becoming more popular for PCPs is Concierge Medicine, sometimes called Executive Medicine. Instead of payment per service, the patient pays a set “fee”, usually yearly, for the services of a Primary Care Physician. In return, the patient receives longer appointments, better service, and access to the doctor by phone or well beyond normal business hours. (Here’s an example) This is often scoffed at as “Care for the rich” but the idea is catching on. In fact, Concierge Medicine is growing despite the recession. Even a former White House physician has entered an Executive Practice. Doctors offering this service have smaller practices and only see patients who are part of their group, although you can usually “buy in” at your first appointment. Costs can run anywhere from a few thousand dollars yearly for access to a smaller practice and more time with the doctor during your visits; up to tens of thousands of dollars per year for special access, 24 hour consultations, telephone contact with your doctor 24/7, and a super-intense yearly physical. The yearly fee eliminates many potential patients, basically creating a private physician.

By committing the doctor to care only for patients who are willing to pay a set fee, practices can avoid the red tape of dealing with private insurance or Medicare. Some Executive Medicine practices no longer accept Medicare or insurance, cash or plastic are their only acceptable payment options. The national population of working physicians is already low; when an Executive Medicine group offers a doctor better working hours, a smaller patient load, and better pay, it will be hard to get him to leave it.

The current healthcare plans will solve very few problems but have the potential to create many more.

No Doctors, no Reform

July 7, 2009

Health care reform in the United States keeps tripping over one fact: We don’t have enough Primary Care Physicians, or PCPs. The PCPs are your “family doctors,” the M.D.’s who aren’t specialists. Really, they specialize in the entire body, providing all types of care and referring to a true specialist when needed. And we don’t have enough of them. In fact, we’re doing as well as we are because the older doctors who are in Primary Care are still working.

No matter what kind of incentives, bonuses, or recruitment tools you offer, there is no quick fix for this problem. Medical school and residency requirements mean that even if you could wave a magic wand and make being a PCP the most attractive medical job in the world, it would still take eight to ten years for the new M.D.’s to start flowing into the system. So we’re going to be here for a while. There’s a proposal – not an official one, but more like a “Wouldn’t it be nice if…” idea – to offer more training to Nurse Practitioners (NPs) and allow them to take on the responsibilities of a Primary Care doctor.  The Happy Hospitalist says no way: NP does not equal PCP, not even close.

So what’s causing the shortage? Debt. When the average doctor knows that he’ll graduate medical school owing $150,000 or more in student loans, who can blame him for specializing? Especially when you know that Medicaid pays 20% to 30% less than what Medicare will pay, and less than half what a private insurer would pay? “In God we Trust, all others must pay cash,” the old saying goes and you can bet that debt collection agencies know that verse very well. No wonder nearly half of all doctors won’t see a patient with Medicaid/Medicare.

So if you think you can “fix” the Healthcare system,  here’s a good place to start.