Robin Cook Writes Fiction

I wasn't going to write about Robin Cook's op-ed piece in the New York Times the other day, partly because so many others already have, but mainly because it really pissed me off and I didn't want to go back to the *angry primary care* thing just yet. Still establishing my persona out here in the sphere, yanno. But all the buzz going around is only about FP's getting paid less because we're less educated than internists and peds; which is wrong, but focusing on that part of it is like responding to someone who calls you lazy, stupid, cowardly and ugly by saying, "Whaddya mean 'ugly'?"

For the record, the piece was about Primary Care being undervalued in the marketplace. No quarrel there. But when I read this part of it:

As it is now, insurance companies — following Medicare’s lead — pay primary care doctors according to the number of patients they see. Each patient visit is generally reimbursed at a flat rate of slightly more than $50. The payment is the same whether the patient is a healthy, young person with a runny nose or an elderly person whose multiple chronic illnesses require many tests, referrals to specialists and detailed explanations to both the patient and his or her family.

I thought WTF. Insurance companies and especially Medicare sure as hell doesn't pay a flat rate -- certainly not "slightly more than $50" -- per patient regardless of how much time I spend or how complex a case it is. Shit, if I got $50 per healthy young person with a URI, I'd be quietly raking it in! Hasn't he heard of CPT coding? E/M documentation guidelines? What the hell is he talking about?

And then he adds this:

A lawyer in general practice is not expected to accept the same low fee he gets for writing a simple will when he writes one that involves complicated business circumstances. Nor does an accountant charge the same amount for a difficult tax return as for an easy one. Why should the work of doctors be assessed this way?

Hey, dude: lawyers and accountants ARE paid by the hour. The simple will or tax return costs less because it takes less time. They charge this way because they can; it's their clients who actually pay them. Hello! Remember why insurances are called "third parties"?

So don't contract with insurance companies in the first place. Sounds reasonable and logical, but there are at least two trivial little problems with that:

1. It assumes that each party to the contract is able to negotiate terms to its benefit. In places like Colorado the major players (who all happen to pay the same fee, but it isn't anticompetetive because the insurance commissioner has said it's just coincidence) refuse to negotiate, telling doctors to take it or leave it, and
2. (the bigger problem) Somehow we have come to a point in this country where patients -- people; citizens -- seem to feel that they shouldn't have to pay for medical care. The "ideal" is insurance paid for entirely by one's employer, with minimal (if any) employee contribution, co-pays, etc. Although most people claim they don't expect all of that, their behavior still reflects the mindset that someone else is paying the bills.

Back out here in the real world, sure we can opt out of all the contracts. The only problem then is getting patients to come to us if they actually have to -- GASP -- pay. Unless (or until) all of us do it, there's always going to be someone up the street they can go to "without" paying (as in, "But doc, they take my insurance.") Still, things are getting bad enough that more and more of us are contemplating exactly that.

Bottom line is that after 30 years as a writer, the only things Robin Cook has in common with practicing primary care physicians is friendships from residency and an MD degree. He may be trying to help, but with premises so outrageously inaccurate he should stick to writing fiction. Oh, wait; I guess he has.