By Hootsbuddy
aka John Ballard
After twenty-plus years as a primary care physician, Dr. Vance Harris is approaching retirement. His observations at The Health Care Blog are a sad retrospective of what has happened to the role of primary care physicians during his years of service. His reflections are personal and professional without being political.
How many dozens of chest pain patients have I seen in the last month who I didn't order an EKG, get a consult, set up nuclear imaging or send for a cath? Only I have the advantage of knowing just how anxious most of these patients are and that they have had the same symptoms time and again over the last 20 years. After a pointed history and exam, I am more than willing to make the call that 27 hours of chest pain is most likely not angina in nature. When I take the responsibility on my shoulders I am saving the system tens of thousands of dollars. Most of these patients present to my office directly and are worked into a busy day pushing me even deeper into that mire of tardiness for which I will be chastised by at least 6 patients before the end of the day. Most of those who scold me are retired and have more free time in a day than I get in a month. My reward for working these people in and making a call that puts me at some risk is at most $75 if I count the less than $25 I get paid for being able to read an EKG without sending it off to be interpreted by a cardiologist. My incentive pay for saving thousands of dollars on each patient for 1-2 days in the hospital, stress treadmill and cardiologist referral is $75. Now there is motivation on a busy day to not send someone to the ER.
A litany of similar vignettes follows illustrating how this doctor saves money, time and avoidable stress daily for his patients. Without blaming anyone he simply observes how the forces of both Medicare and the insurance industry produce a sad unintended consequence, the undervaluing and steady decline of the primary care physician.
I continue on in my 22nd year giving advice and services to 30 plus patients each and every day. Having me in the system has resulted in savings in the hundreds of thousands of dollars each and every year. My financial incentive to hang in there and work hard is the following. Twenty years ago I made about twice as much as I do now. This year I will make less as it seems even more of the claims are being reviewed while payment sits in someone else's account drawing interest.
A long comments thread follows with "Amens" from other doctors mixed with other agendas. (Insurance apologists are as ubiquitous as bacteria.) One contributing factor to escalating costs is patient requests (demands?) for tests and/or referrals that are not medically indicated. Rather than allow the doctor to make the call or manage their case with a less costly, even more effective course of treatment, patients today want medical results with the same urgency that they want everything else, Now.
I can relate. As a cafeteria manager I watched democracy in action every day for years. A cafeteria line is a study in human behavior. As long as the line keeps moving everyone will shuffle along and wait patiently. But if the line slows people become impatient. The ultimate contradiction is how quickly attitudes change as people are being served. The unspoken but plain message from someone waiting is "Get this line moving. Hurry up, I'm waiting." But when it comes that person's time to be served the message is "Don't... Rush... Me... Give me time... to make up my mind."
A psychologist left the following comment. I think she's on to something.
You make such good points and I empathize with your plight! I am a clinical psychologist and I couldn't help but notice as I read your post that many of the people you mentioned who came in with physical symptoms, you seemed to suspect were actually having anxiety or depression. Our whole healthcare system discourages prevention and it also discourages mental health treatment. Just as primary care doctors are grossly underpaid, so are psychologists and social workers. The current system discourages us from working collaboratively with other providers (for example, calling the primary care doctor to talk about what contribution mental health issues may have or may not have in a particular patient's symptoms). It discourages us from trying to solve anything without immediately suggesting psychiatric medication, which certainly has its place in some situations but not all and is not a panacea. It is so frustrating how far the existing healthcare system is from actual provision of care to patients and our ability to manage financially as providers.
At the end of the list came this recommendation from a doctor advising others to quit the system altogether by setting up a boutique practice. This is not widespread, but it's a growing trend. Smart doctors and savvy patients with enough money to retain therm are catching on. This model is the simplest of cooperatives: one doctor with a limited patient population. I'm not sure how it works when it's time for specialized procedures or consults, but until then insurance is not in the loop. I became aware of this trend about two years ago.
...If someone wants to practice primary care and do it just to make money it is really pretty simple. Stop billing insurance.
Work on a flat fee of 50 to 80 /month per patient, cut your practice down to 1000 patients (600,000 to 1million gross), get ride of the billers, have longer visits. and do all of the preventive, counseling, hands on care that so many people need and that our society would appreciate.
"But if the line slows people become impatient."
ReplyDeleteActually, due to several years of experience which I am not at liberty to discuss in detail, but which involved studying lines at food serving stores over a fairly wide area, that is not quite true. The customers' attitude is greatly influenced by the demeanor of the servers. If the servers are highly active, are making eye contact and interacting with the customers, the stalled line does not result in the customers becoming impatient even for significant periods of delay.
Very minor point, of course, which does not invalidate anything you have to say, but I always was quite fascinated by the effect.
Lately, due to some "health challenges," I have been spending a good bit of time in doctors' offices. I can tell you that delays are far more tolerable when a staff member explains and/or offers times frames for them. "Sorry the doctor is running late. It shouldn't be much longer."
You are correct, of course. I don't think I'm giving away any secrets when I say the trick to moving a line is to rush people without letting them know they are being rushed. A well-trained staff doing all the right stuff (eye contact, clear voice, pass the plate promptly to the next server down-line who then passes it to the customer, reading eyes before waiting for the verbal order, etc.) can easily serve over a hundred meals every fifteen minutes and never seem to be rushed or make customers feel rushed. (And not to push the analogy too far, the line manager is really the variable making a difference.)
ReplyDeleteI have a feeling that in the case of this retiring doctor he's being too modest. I sense from what he says that he's the kind of physician most patients wish they had and his patient base is solid as a rock. Being "chastised" by his patients is obviously not high on his list of troubles because they both know they will be as faithful to him as he has been to them.
Teach and trust doctors to diagnose without technology, as in Eastern medicine. I don't care to be lumped in with those who are anti-litigation. But doctors also need to be freed from worrying that their test-free diagnosis will result in a malpractice suit.
ReplyDelete