Home Forums Discussions General Discussion Reforming primary care

I am curious what people think about the discussion surrounding primary care and how it can be strengthened. Every few days now I read articles about how important primary care is yet when I read about some of the solutions proposed, I can't help but think that the writers (and policymakers) just don't get it. I want to write an op-ed piece to submit to a national newspaper yet I'd like to get other people's thoughts first. I am deliberately not sharing more of my opinions in this post, yet the view from my foxhole is based upon a practice which is heavy in geriatrics and lots of coordination of care with specialists. Thanks in advance for any insight/input.

Most outside people and specialist have little idea of what primary care docs do. It also varies depending on the practice, the community and the insurance mix.

Gatekeeper. You keep hearing that statement over and over, but ouside of HMOs, you do not have to act as gatekeeper, but probably should. That then depends on how the patients perceive you as well. there is no real reimbursement for gatekeeping so it must not be important, ha ha.

I am on the other end of the spectrum in Pediatrics. We actually do a lot of preventive medicine, counselling and then there are the multiply challenged kids who require a lot of specialized care.

Med refills, reconciliation, referrals, coordination of multiple specialists, translating information from the specialists. Taking care of the routine medical problems and providing preventive care. Often assisting in getting benefits, completing tons of paper work, explaining insurance choices and coordinating insurances, all of these fall into primary care.

Of course after hours phone calls are not important as they are usually not reimbursed. Most insurance companies require that you have 25 hour availability although they do not reciprocate.

Of course our reimbursement rate have always been procedure based, so primary care docs, especially pediatricians, have lower rates of reimbursement. It would be a lot easier to do 2 hernia surgerys a day than the complete coverage in the office. But then, we have more fun.

If we could set our rates and get paid for them and actually have a competitive environment.

Drives me crazy that I get a Mainecare reimbursement for a 99213 of X dollars, while the FQHC across the street gets 3X.

And, don't forget the prior authorizations. I love that we are four hours from some of the best medicine in the world in Boston but, if you are Mainecare, you can't go. That's unless you can convince an RN who sits in Augusta, Maine.

Don't get me started.

Leslie

It seems, going back to the original question, that we are saying that the best way to improve primary care is to improve the reimbursement, which is true.

Much of the bureaurocratic side of our jobs (much of referrals and such) is a waste of time. I should be able to bill every time I have to call Caremark and spend 15 minutes on the phone for a common medicine, then the insurance company would think twice about the SAVINGS that they are acheiving.

I would love to bill for my services by 15 minute block, like an attorney or accountant. IMHO, it really wouldn't affect patients one bit, since the RVS codes (99XXX) would probably not be changeable. But PAYING MY RATES for the other trivialities, the ones that detract from patient care and make your blood boil, would EAT ALIVE those blasted insurers and managed care companies. Wishful thinking.

Anyhow, has anyone seen any "Change That Works" yet? Let me know...I just don't want to miss it.

Doesn't matter what Obama does now anyway. Much like global warming, the primary care crisis is already too late to stop. The comparison between the two is apt. Almost 10 years ago, family practice residency positions were going unfilled, and less than half of internal medicine residents headed for primary care (it's now down to 20%). The media and our national leaders are still wringing their hands, and then the latter pass new rules to let Medicare and the insurers stick it to us.

I was at a CME talk on Type 2 Diabetes last week, and, as you may know, there are 23 million diabetics already, and 57 million pre-diabetics. At present rates, one of three kids born in 2000 will be a type 2 diabetic some day. Crunch those numbers, plus the fact that half the endocrinologists and half the internists in practice today are over age 50, and we should probably put the money toward building dialysis units and nursing homes.

I will take no pleasure in saying "I told you so" when the meltdown comes. I want someone like me, to take care of me and my family when I'm older.

I can't help but weigh in here, although I know very little about the entire process.

The main reason we get screwed over is because we LET ourselves get screwed over. Do you think the lawyers we keep referencing would allow the government to make them go through 3rd party payers? And, yet, we have more leverage than any "business" in America. Our organizations such as the AMA, AAFP, AAP, etc. are already organized and could easily lobby on our behalf. But, they don't. My local medical society has four barbaques per year and sends out email invitations. That's helpful

And, before someone tells me that if we "went on strike" and didn't accept Medicaid, etc., it would be considered illegal, I would still before it. We are not public or civil employees. At least not most of us. I doubt it would take a week to force the insurance companies to sit down with physicians to negotiate reimbursement. What incentive do they have now? None, except as John says, it will collapse one day.

The other reason the situation is due to the fact that the law makers truly don't understand the problem. Which is why when they try to fix it they won't be able to. Yes, the lawmakers may not care, but I am willing to bet if they knew the reality, a lot more would try to actually help primary care. Let me give an example, and I apologize in advance if I am patting myself on the back. But, I think it is a powerful example.

In my state, beginning January 1, the state no longer covered vaccines for non VFC children. VFC = Vaccines For Children and to qualify you basically had to be Medicaid or unable to pay. Physician's offices were forced to purchase a second supply of vaccine to keep on stock to give to the privately insured patients. They then had to bill their insurers. Well, you can see the nightmare. I emailed every single representative and senator. Nothing happened. I then talked to someone about it who happened to know the governor. I got a call the next day from the governor. He talked to me for over 15 minutes, and the rest of my day was spent talking to DHHS and Medicaid and the immunization councils from my state. Two days later, he proposed $2,000,000 to allow universal coverage for all children in my state. It still needs to be approved. I am testifying before the house and senate committees this week. I was told by one of the higher ups in the immunization councils that all this happened because the governor had no idea this took place.

I am willing to bet that very few congressmen and women know the true plight of primary care physicians.

>>> I got a call the next day from the governor. He talked to me for over 15 minutes, and the rest of my day was spent talking to DHHS and Medicaid and the immunization councils from my state. Two days later, he proposed $2,000,000 to allow universal coverage for all children in my state.

Wow Bert! You rock! Sometimes we have to take the bull by the horn and fight back. Go get 'em.

You should talk to Jon about running for office... didn't he run for some sort of state mayor or governorship? If you follow his lead, then you'll be really rich. None of this doctoring stuff. Kickback here, kickback there... you know- something WE can't do. ;^)

Al

Al,

Thanks for your post. I really appreciate it. Wish me luck on Wednesday.

Bert is of course right. We have allowed ourselves to be duped. We have the wrong set of ethical principles to win this battle.

Like our fellow citizens who have lost their jobs, retirement, health insurance, homes, etc. in the economic meltdown, we assumed the people we elect will do what they were elected for, and what they promised. Instead, they accept money for influence and fail to do even the most basic investigation before they pass legislation.

Look at what is happening with health care reform now. Obama giving a speech on healthcare reform with Allscripts' CEO and election contributor Glen Tullman sitting behind him (Allscripts asks $18,000.00 per physician license for their EMR). Now Senate Finance Chair Max Baucus is accusing the Congressional Budget Office of obstructing the administration's health care plan (with hard financial facts). Politicians only believe the facts that support their positions.

Most of them are attorneys. "Attorney ethics" consists of taking the position you are paid for, and manipulating the facts to support it. I have also taken part in "lobbying days" to talk to my state legislators. A couple of practicing docs and I sat in a waiting area with a half dozen lobbyists for our 10 minutes. For our time we got smiles and excuses. Oh, and the state senator's aide called back later asking for "re-election support". These people don't deal one-on-one with a sick person in the office with no resources. Unlike us, their money-based value system allows them to dismiss such people as unimportant.

I wish I could recommend a physicians' strike. Does anyone remember what happened in Saskatchewan, Canada in 1962 when 90% of doctors closed practices to protest a compulsory, government-run health plan? The province brought in doctors from other provinces and Britain's NHS, set up clinics, and killed the strike. The doctors that went on strike were demonized. The provincial governments rolled out their present system with no significant physician resistance.

Nothing in our government...health, welfare, transportation, security, life, liberty or the pursuit of happiness will ever be achievable until we outlaw lobbying. Lobbying, IMO, is the apple dangling in front of Eve. If Congress deems physicians criminal for accepting a pen with the name of a drug company on it, then surely, they are ten-fold worse.
Pay our representatives a very nice salary which should be the lone stimulus for their loyalty to their constituents. Severely limit party contributions to one's election, for the political parties also are nothing but lobbyists.
To me, these two things seem so simple to achieve. And, nothing will ever serve The People more readily than representative who truely serve The People, rather than the pocket-gilding by special interest groups.
Americans of all economics walks should stand up strong and demand this legislation.

Leslie

Yes, but Leslie, you have to take into consideration occurrences like this.

A three-year-old with new onset of moderate persistent asthma is on my exam table. I tell the mother she needs Pulmicort and Singulair as well as albuterol.

But, the three-year-old looks down at the exam table paper with its purple Advair brand and demands Advair. That was when I saw the benefit of the government mandate.

THIS, OF COURSE, WAS ALL SARCASM.

I found an article from 1986, which references some doctor strikes. The author makes a good point about having public sympathy on one's side if a strike is to be successful.

This is where our organizations such as the AMA have dropped the ball in my naive opinion. How can the lay public know about the PCP's plight when 90% of all Americans still think that Influenza is synonoymous with gastroenteritis. I gave up a long time ago on that one and just go with it. Even today, my patients keep calling me with enteritis symptoms thinking they having N1H1. Not to even mention that any temp over 99 is a fever and every day with a fever is one day closer to death.

Maybe this is not a good analogy, but I have little sympathy with baseball players when they strike, because they only make $5,000,000 per year. And, I swear I will never watch them again. But, guess what? They get what they want whether society likes them or not, and I keep watching the Red Sox and baseball revenues continue to go through the roof.

I already feel as though 20% of my patients don't respect me, so I think I would rather have all of them disrespect me and have less paperwork and more reimbursement. The article can be downloaded below:

http://www.box.net/shared/static/1skrrfbpm1.pdf

PS Leslie, I sincerely apologize to being part of getting you started, lol.

But the real question is, did you give the kid Advair?? Would your existance, sustenance, reason to exist have been affected if you did not and the drug rep never brought you any more table paper? Big difference. These politicans rely on special interests for their jobs.
I wish I could say I think a doctor's strike would work. But too many people still think we are greedy SOBs. And, with or without a strike (sorry Carla), insurance companies would love nothing more than to get rid of primary care MDs and replace them with PAs/NPs who are cheaper. A strike would only open this door for them. So, once again...be careful what you wish for.

Leslie

Doctors will never retake control of medicine because we are not as ruthless and cutthroat as all the other stakeholders in the system. They play the political games and are willing to put the best interests of the patient secondary to profit, which few physicians are willing to do.

It's not just the insurance companies, there are the hospitals and pharmaceutical companies as well. The amount of money spent on drugs per patient is about the same spent on PCPs, twice as much goes to specialists who have much less contact. What is wrong with the system???

The system is broken, has been for a long time. And, though I agree completely with Leslie, this is what the system counts on.

One of my lawyers who specializes in healthcare, once told me he finds it absolutely unbelievable that physicians put up with this. If you really look at it, among the hospitals, insurance companies, drug companies, whatever; the physicians still are the most powerful as far as the pyramid of healthcare.

Our patients think we are rich SOBs, well they would think we are rich SOBs trying to get richer. Either way, they would think the same. But, as the paper says that I uploaded, it is extremely helpful to have the support of the people.

Wait..didn't Jefferson say that? Or someone way back when.

If you want to learn about cut throat hospitals and hospital systems you should read the book "Coronary: A Trus Story of Medicine Gone Wrong" by Stephen Klaidman. I ttells of doing CABG's on patients with normal cardiac caths just to make more money. It only takes a few bad apples...

Well you know the old saying.

Now see, I would love to have some discussions like this at our next ACUC meeting. Let's broaden the topics to include more than just the use of AC. Let's get some people who are "in the know" to help us learn what we as physicians need to do. Everybody is talking about it. Everybody is giving their opinions about what the problems are. But very little is being said (especially from our medical societies) as to how specifically can we start changing things...NOW...not 5-10 years down the road.
See, not good to get me started.

leslie

Call me cynical, but I do not see PCP's getting together as a large group to accomplish radical changes in our health care. We are trained to be independent thinkers and to be confident about our decisions. That makes it hard to be great team players. Talk about too many cooks in the kitchen!

It all comes down to money. Whether it's" greedy" corporations playing the middleman and contributing to the demise of our current system or getting the government involved to take things over, it will still boil down to money. Just wait to see the congressman fight over who gets to be on the health care committees because they know they will stand to make a lot of money off of the lobbyists who will come knocking on their door offering to contribute to their reelection campaign or their PACs.

No, I don't pretend to know the magic solution to the current health-care problems. But right now, it looks like the difference between frying pan and the fire. Either way, it's just going to keep getting hotter!

Well, we may not be able to get together to make radical changes, but we ought to have a seat at the table when Medicare rates are being discussed.

I agree Bert, but why are they going to listen to us if we can't come with a united front. Beyond that, if they don't agree to our demands, what will we do? Strike? You just illustrated the pitfalls of that strategy. I think getting doctors together is not impossible, but is probably something that akin to cat herding(I wish I knew how to put a link to a video for the commercial that showed cat herding).

Greetings,

My name is Mario Maurizi and, I this is my first post on this or any forum. I have been visiting and gleaning this board for a month in an effort to help my wife, a solo NP trying to implement AC.

I stumbled onto this thread and am compelled to reply. These posts from 4/29-5/4 speak volumes to your credit, and to the dark era the USA has been enduring. Words from some of you moved me emotionally. I recognize your frustration, anger and feelings of helplessness.

In my former life, I provided health insurance to my employees.
We all hated the insurance companies. My employees knew that it was more doable to buy group health with pre-tax dollars than make higher wages and have to provide for their family's medical needs and catastrophic coverage. We still had to compete against companies that did not offer health insurance. It cost around $8 an hour to insure an employee and family in a mediocre HMO.

The thirty years of we-they propaganda that has divided Americans is poison to be avoided. Trust that people know the difference between a rich sob and someone who works hard and is
well compensated for it. There are a many tens of millions of people/patients/families as frustrated, angry and feeling helpless as you. They need truth, not the sound bites they get now.

Better stop here before I go on a rant, but know that as a cynic who has been bored and disappointed with my fellow Americans, You gave me a little hopeful lift. My virtual hat is off to you.

Mario Maurizi
Office lackey

Welcome, Mario.

As one of the most ranting contributors on the boards, I appreciate your company. I know my patients (not all but many) are very, very worried about the upcoming proposed changes to health care. They are not confident that the current government will produce a viable solution for them. It may be great for those "underprivileged" patients but not for the hard-working middle class. I had one patient comment to me this week, "I have no problems with the meek inheriting the Earth. I do, however, resent the stupid and the lazy getting it all."

On another note, I have as a patient probably the biggest malparactice lawyer in my community. He was in the office the other day and telling me how he had seen an orthopedist in town for a shoulder problem. He is also defending this doctor in 2 malparactice cases. The two exchanged professional advice...the ortho advising treatment for the shoulder, the lawyer advising the course of the legal case. When the lawyer left, he had made $150 and the ortho $60. Speaks volumes.

Leslie

Last week, I had the opportunity to hear a brief talk by Cecil Wilson, who is the incoming AMA president. Now, I don't expect the AMA or any other of our professional organizations to aid us in getting any help for primary care docs in the so-called reform that is coming; they serve too many masters. But some of his comments were interesting.

After being involved in Washington lobbying for almost a decade, he estimated less than a dozen administration officials and legislators had any understanding of the issues that need to be addressed in healthcare. The average senator doesn't even know about his own health care delivery and reimbursement, even less about his constituents' needs. The majority will just read the executive summaries provided by their favorite lobbyists and party blocks, and act accordingly. All the impassioned speeches on C-NET are scripted.

We are all watching a puppet show every night on the 11:00 news.

That is one of the greatest quotes I have ever heard.

Welcome Mario. We welcome your contributions to the board. Please be active. Unlike the partisan government, you are free to give all sides here both technical and political.

Leslie says she rants, and she does, but she is one of the smartest voices on here. (I'll take a case of Heineken, Leslie).

John, you are so correct. For those who watched the Clemens' hearings (just a great use of our highest lawmakers and watched as one of the senators refer to a player by the wrong name and the wrong stats (which were obvious), you can see the John is correct. I would love to give a pop quiz and see how many know what a 99213, CPT code, FQHC, RHC and the various reimbursements of Medicaid vs Anthem. It would be shocking.

It would make much more sense for people who have proven themselves, the Lee Iacocas, the think tanks, the physicians and mid-levels, nurses, etc. to look at it from a business point of view. Sorry, I don't even know if Lee is still around, lol. Even Jon has taken strides to show that a doctor from Providence, RI could build a program and sell it for pennies on the dollar. I have put a statue of Jon on the main road of Bangor. OK, so it looks a bit like Paul Bunyan but still.

Hell, I would put Paul as the president of such an organization. I will never understand why the AMA, AAP, AAFP, MMS (Maine), MMA do nothing but sell Red Books and throw picnics when they should be backing up our cause.

Hahahaha...Bert...Your Heiniken is on its way!!

Leslie

It is obvious that the news is scripted, but most of the American public buy it hook, line and sinker.

The congress is run by people who are mostly millionaire lawyers. Some made their millions, others inherited and the last picked it up from the lobbies. Few have any expertise in health care. They are influenced by lobbiests who get their ear by throwing perks. Of course, lawyers make more an hour than doctors, look who writes the rules. Can we easily charge for telephone conversations and get paid for it?

They internally outlawed pharmaceutical companies from giving away pens because that was felt to look like having too much influence but it is OK to do much worse in Washington. Just that no one makes it public, and when they do it is quickly swept under the table.

Our "trade organizations" are under the same issues. They are being swayed by lobbbys more than they are swayed by average physicians.

I would like to be optimistic but I can't see a way out until someone famous or family member or congressman gets affected by the the health care most Americans have and it becomes public.

Think bigger!

All that is not fee for service is not necessarily commie pinko socialized medicine.

The medical industrial complex wields tyrannical power that King George would have envied.

Anyone proposing a constitutional amendment making health care a right?

I did well as a capitalist,believe strongly in capitalism but, unbridled capitalism will reduce us to oligarchy. In our system that seems to enshrine the right of corporate execs to make 5 or 50 times the income of supreme court judges, it's easy to predict who would become the oligarchs.

I like regulated monopolies for infrastructure industries that are necessary for life as we have come to know it. I think electric generation and transmission, telecommunications, mass transit and health care easily make the cut into that category.

Deregulation and privatization were first sold as getting the government off of business's back, and lowering prices by promoting competition. It was also going to promote innovation.

What we got instead were the likes of Enron, Haliburton, United Health Care, last year's legendary profits of Exxon-Mobile, an aging, failing power grid, falling bridges, Medicare part D and; whoda thunk it,a wall street collapse. Try to read your phone or electric bill.

Given the time this group devotes to unnecessary "CYA" documentation, who is on your back? Whose back did the government get off anyway? Yours?

Fore those who still remain watchful that big brother is in our future, look again, he's on your back already, he's an industry with a big lobby. What the heck, why shouldn't Google or Microsoft manage all the medical records, Walmart for that matter, we know they would have the common good at heart, altruists that they are.

So the government is not off your back instead it let the med-ind comp ride along. Price of health care is not down,though reimbursement may be. As for innovation, lifestyle drugs got sexier but what drug co. is putting its own money into what you need? When was the last new antibiotic introduced?

How about an auction, Health insurers put up around $50B to bid on the right to be a regulated monopoly,the single payer, guaranteed 5%profit, administer plan defined by other than themselves.

How about no-fault malpractice insurance, patient pays insurance against medical error?

I would go on and on but I,m out of time.

Mario Maurizi
Office Lackey

Mario, you hit this so far out of the park, in my opinion, none of the baseball home run kings of the last 10 years would even come close.

The cost to insure a family has increased but the reimbursement to physicians has not. Where is that extra money going? It is going to people like Bill McGuire, former CEO of United Healthcare, who took a 1.6 billion dollar, retirement package.

I would gladly accept single payer. It would reduce my payroll expense by $34,000, for the employee that has to deal with insurance verification and all of that. It would also save me another 6.5% from having to pay another company to process and submit my claims to the 40+ insurance companies. That would save me another $20,000 - 30,000. Now couple that single payer system with a modest 7% re-imbursement increase, and you have added at least 100,000 to the primary care physicians bottom line. But we can't have that, it's socialism.

As a service provider, I only care who pays me, if the manner in which they pay me affects my bottom line. Right now, having to deal with multiple insurance companies, dramatically affects my bottom line.

The next big free fall seems to be the patient centered medical home model. Every conference I attend and every person I speak with seems to be head over hills into this model. I think like most other booms this will make some well positioned individuals very rich while not really fixing anything. I really beleive the real problem is the administrative cost we as docs have to incur in putting our product out to the our patrons. It is not only insurance executives but hospital ceos, dme ceos, head hunter ceos and all the middle men who are taking a lions share of compensation that should be going to the care of the patient thus our reimbursment. A lot of individuals positioned just perfecttly to be medical directors of the large PCMHs will likely become very wealthy while many of us who are actually providing excellent evidence based care will continue to suffer.

Single payor insurance would simplify things tremendously. It would leave you subject to whatever rate they pay, but it would be one rate. I, for one, take medicaid in IL that ranks something like #42 on the reimbursement scale (the low end) thus, I could only do better.

Malpractice should be like vaccine insurance, doesn't have to be government run but should be a pool throughtout the country. Claims should be adjudicated by a panel of experts to determine the merit. Physicians who are out of line or radically, repeatedly perform poorly should either be reeducated or find a different line of work.

Sounds socialistic? I prefer any system that does not leave 40% of the American public underinsured, physicians working with unfair reimbursement and an entire insurance industry designed to obsfucate on all sides of the spectrum so that a very few people can make an obscene amount of money. Capitalism is the best system in the world but medical care CANNOT be laiz se fair (sorry about the spelling)

I have suggested Doctors agree to single payer in exchange for Collective Bargaining.

But then "they" would be giving us 2 things we want. "The System" is afraid of collective bargaining because they do not want Docs to actually control any part of the cost structure.

I don't get over here too often, but thought I would share this post I did at the blog, kind of scary, the webcam part seems to be ok, but the esync is a bit scary and I think misleading and it tends to have a rub with the patient/physician relationship, and this is going to be available all over the US.

What if every payer starts this is my question and the esync information is a bit misleading as it seems to represent the fact that they seem to think they know better. The one that stands out to me is the man needing back surgery and they come back and state that he was better off with chiropractic care and how it saved money. Anyway, this seemed to fit here with some of what is going on with primary care.

http://ducknetweb.blogspot.com/2009/06/optumhealth-subsidiary-of.html