Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Tuesday, September 19, 2006

Follow the Money (Guest Rant)

One of the reasons we dinosaurs have three feet in the tar pits is the increasing difficulty we're having making a living. Only in this country do we have de facto price controls on doctors' fees (ie, Medicare) and over which we have no control. What to do?

There's a growing rumbling about in the land. "Cash only", the rebels intone. One by one, a few docs here and there throw up their hands and bite the bullet (often to do quite well, but obviously with a different patient mix. Some of my personal reluctance to go that route stems from my sense of responsibility to my present patients. But I it appears we dinosaurs are prone to.)

How might this be accomplished more systematically? This, too, has been discussed in assorted circles, both public and private. My friend Dr. P says it well:

We ALL together DROP all insurances. We announce a D-day, nationwide. We dump tea in the harbor; taxation without representation, off with King George's head!

We tell the patients that it's a new day. Forego one dinner and movie out and you can pay for your doctor visit. Payment due at time of service, unless there's real financial hardship. Hello? If you're too poor for that, we'll see you for nothing. Those of you with six-digit incomes can subsidize the difference.

Everyone buy a rock-bottom catastrophic policy for duh? insurance (what insurance is supposed to be: spreading risk of accident or severe illness, not everyday gas and oil). And sock some money into the now-allowed HSAs tax deferred. Keep your money instead of p---sing it away to "insurance" companies.

What a concept. Sound familiar? Sound retro? Sound like the rebirth of common sense? (Have you read Philip Howard's The Death of Common Sense?)

Forget about coding. It's useless for its original purpose: to collate real disease. It's useless because we have to code for the disease in order to test for it. We have to assign a code even when we haven't a clue what's wrong with the patient. No one's codes are believable anyway. They're all fudged and we know it. (Admitting is is a different story.) Hospitals fudge for highter reimbursement -- we sign and go along as we look the other way.

It's also useless for equalizing reimbursement bewteen primary care and procedures. The RBRVS was a valiant attempt, but all that emerged were armies of coding specialists who now earn more than the family doctors, and whom we now have to hire and pay. Forget about studying real Medicine: time to learn Business Management.

Everyone wants to know the way out -- this is it.

But it all depends on the public being led, step by step, to understand that this is best for them, not just for us. And it depends on our not being afraid to do it. Courage.
It would only work as all-or-none, but I'm just on the edge of being ready to give it a shot.

Anyone else?


At Tue Sep 19, 08:28:00 AM, Anonymous Anonymous said...

It's funny that you should write about this today. I was just thinking about this from the patient perspective yesterday while I was looking at private health insurance options. I added-up the premiums, thought about how many times I really need to see a doctor, etc. If I deposit the premiums into my savings account, I'll have plenty of money for the doctor's visits (and some left over). I just need to make sure that I have insurance coverage for a major crisis . . . Yep, sounds reasonable to me. Go for it.

At Tue Sep 19, 01:42:00 PM, Blogger Dreaming again said...

As a patient with one of those "real diseases" these concepts make me panic.

I'm in one of those catestrophic cases and I see me becoming a fatality of the system. (literally and figuratively)

I have labs done every month, see my PCP every 8 weeks, and my specialists more times a year than I can count, because each one needs to see me at different rates for different reasons. (my PCP does a better job of managing it all than I do!)
My medications come to more than double my monthly income and if I were to pay for doctor appointments ... we would have no income. That doesn't include my husband and his issues due to polio.

I've been on medicare part D since it started January 1 and I hit their catestrophic care half way through May, meaning ... I pay nothing for my co pay for the rest of the year because the costs are too much and enough has been paid.

I go through my life pretending I'm normal, typical person, but I'm not. And the medical stuff gets me frequently ... Catestrophic only begins to cover it.
(Dr. Dinosaur, I'm new to you ... short list of diagnosis ... includes myasthenia gravis, lupus, asthma ... and there are others and the lupus has a few complications *sigh* yes, i do try to pretend to be normal, life is more fun that way)

At Tue Sep 19, 07:43:00 PM, Anonymous Anonymous said...

There's a perversity in the system now: it actually discourages excellence. Since a given service is paid the same by insurers/medicare whether or not the service is better than that provided by another, there's a disincentive to putting in the extra time and effort that excellence requires. My brother is a very high-level attorney, evidently among the best in the country in his particular field. He charges by the hour, and a pretty penny indeed. And his clients are glad to pay it, because they know they are getting the best. If that was ever true in medicine, it certainly no longer is. People who have an ethic of excellence will look elsewhere than medicine for careers, because it's no longer about excellence in our field. I'd love to see what would happen if your friend's idea were to come to pass. But, of course, the insurers know they're in the driver's seat: as long as doctors are worried about their survival, enough will buy into what the insurers are selling.

At Wed Sep 20, 12:28:00 PM, Anonymous Anonymous said...

I certainly don't have the medical problems that Peggikaye has, but I have several related chronic illnesses which would be more than my husband's salary could ever come anywhere near covering. A few years ago, my medical bills when into 6 digits ...

If there were some sort of failsafe for catastrophic illness, then I believe that what your friend would like to see happen is the only way healthcare is ever going get past the crisis it's in today.

Taking insurance companies out of the picture would immediately lower costs all around.

We'd still need to do something about unreasonable litigation, too ... and the constant threat of lawsuits which also drives the cost of healthcare through the roof.

Not sure what we could do about all of the over the top government regulations through ... that would be trickier ...

At Thu Sep 21, 09:59:00 AM, Anonymous Anonymous said...

Most physicians who complain about money fall into two categories. The first don't see enough patients and aren't efficient with their schedules. The second live in poverty-stricken areas (either inner cities or remote, rural areas. There are hundreds of thousands of doctors who do extrememly well. What do they do differently than you do?

At Sun Nov 12, 02:03:00 PM, Blogger Sara said...

Where did the original article/post run? I'd like to look at the whole thing and maybe pass it along.


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