CMS Proposes Primary Care Raises Funded With Specialist Cuts

[DrAwsome]

So you're saying the current pool of providers and applicants are of lesser quality yet deliver greater results? And simultaneously say that improving the quality of the applicant pool (by drawing from the dumb, evil specialists with higher pay and lesser outcomes, no less) will improve the overall situation?

Yes, sound thought and logic is strong with this one.

Thanks dude. I don't think that this person realizes that the proposition of more pay for PCPs really does nothing to address the issues at play. We can pay more money to PCP folks all we want, but I guess their inuendo is that current PCPs are not delivering good care, so more money will deliver better care with better applicants. So in reality their argument is current PCPs suck. But I guess no one is willing to address the point that millions of people still won't have access to care given the limited # of PCPs and the many more people that need care.

And as you point out the logic is extra faulty.

---

Members don't see this ad.

 

[DrAwsome]

.

 

[DrAwsome]

I'm going to help you out here, mr. burger, because I'm a good guy.

bigkahuna premises:
1. PCP care good, specialist care bad
2. PCP underpaid, specialist overpaid
3. PCP need make more $, need take from specialist
4. PCP residencies need be more competitive. Need more $ from specialists to give PCP so more competitive students want to be PCP

There are a number of underlying assumptions readily apparent to anyone with an above median intellect in the above premises that should be found rather insulting to PCP's everywhere. I have said time and again, over a number of years that likely exceed the length of time you have been legal to drink (possibly drive), that the primary hurdle for PCP pay is a lack of distinct billable services for all of the **** they have to do. That's the problem. The problem with PCP pay has precious little to do with what the retina surgeon nets; it has everything to do with the amount of uncompensated work they provide.

But feel free to keep making asinine (and frankly insulting) arguments. It does make for a grand indictment of the current education system.

Yep. Apparently per "mr burger's" comments, PCPs are incompetent and underpaid, and specialists are evil, overpaid and better I guess.

He/she fails to address though how taking money from evil specialists and throwing it at PCPs will help the millions of people who can't even get care since there are not enough of them to go around. Oh well.

 

[MOHS_01]

So you're saying colon cancer screenings, breast cancer screenings, diabetes control, skin cancer surveillance, hypertension control ect which form the basis of disease in just about every case I admit to the hospital (not to mention PCPs controlling endless readmissions of those who already have CHF, COPD) are wastes of time and MOHS surgery, can you say CA-CHING and yearly cardiac Caths helping to supply the nephrologists with new dye induced renal failure and cardiology NPs causing lasix induced chronic kidney disease for patients with bogus CHF diagnoses are where it's at.

Oh, sorry -- missed that gem. Skin cancer is rather unique, actually. It is one of the reasons I do what I do, by the way. If you're good at it -- which some are, but many are not -- it can be hugely cost effective. Why? Because of the unique exposed nature of the skin and the piss poor reimbursement for E&M services, that's why. You can catch it when it is cheap and easy to cure with a relatively cheap and simple surgery. No expensive chemo (which does not work). No expensive radiation (which does not work very well). No hospitalizations (well, for the vast, vast majority).

 

[bigkahunaburger]

Thanks for being a good guy MOHS:

You saying "lesser quality yet deliver greater results?" Ok, first off, we're comparing primary care to dermatology, there's no doubt that primary care is more "cost effective" and certainly "appropriate". But I'm glad you were able to string all those pieces together. And "insulting to PCPs everywhere", not at all actually. Students aren't choosing dermatology over primary care because of the wide array of cases they get to see, it's the compensation. I don't think many people would argue that to get a derm residency you have to have top board scores correct? I also don't think many would argue that because of compensation primary care has become less competitive, ie lower board scores. Does this mean ALL PCPs are of lower quality, only if you assume everyone is as money hungry as I'm sure 80% of your derm buddies are. That damn ACA, trying to recruit more students into primary care by increasing compensation, they must think they're all stupid right? You tell me though, if compensation is increased do you not think we would have less IMGs able to match into primary care and more US grads that do, does this not increase quality?

 

[MedicineDoc]

Thanks dude. I don't think that this person realizes that the proposition of more pay for PCPs really does nothing to address the issues at play. We can pay more money to PCP folks all we want, but I guess their inuendo is that current PCPs are not delivering good care, so more money will deliver better care with better applicants. So in reality their argument is current PCPs suck. But I guess no one is willing to address the point that millions of people still won't have access to care given the limited # of PCPs and the many more people that need care.

And as you point out the logic is extra faulty.

No Dude. There aren't enough PCPs and they dont get paid enough dude Dude? The current primary care physician is overworked and underpayed forcing him or her to see patients on 15 ot more medications most of whom have CAD, HTN, DM, CKD, CHF and or COPD in addition to arthritis, chronic back pain, obesity and various other problems all in about 10 minutes in order to keep the office afloat. Get it dude.Not including the reams of ridiculous paperwork.

 

[Smokemont]

HOW will MORE money to PCPs FIX the ACCESS of patients? Are you unable to understand this or what is your problem? It's like i'm talking to a wall.

I'll say it again- HOW will MORE money to PCPs FIX the ACCESS of patients and better outcomes? I think the system is more than fair. Of course specialists would make more. No reason for them to make less.

You should call around to your local family physicians and tell them you are a medicaid patient and see how many appointments you can get. I'm guessing not many. Why? Because FM docs actually lose money when seeing these patients (based on those I've talked to). The logic here would tell us that by paying PCPs more money you can increase access. I'm not saying this would fix the problem, but it could help. Unless I am missing something, in which case please educate me.

PS - I don't think specialists are overpaid and do not support taking money from them, at least not too much

 

[DrAwsome]

No Dude. There aren't enough PCPs and they dont get paid enough dude Dude? The current primary care physician is overworked and underpayed forcing him or her to see patients on 15 ot more medications most of whom have CAD, HTN, DM, CKD, CHF and or COPD in addition to arthritis, chronic back pain, obesity and various other problems all in about 10 minutes in order to keep the office afloat. Get it dude.Not including the reams of ridiculous paperwork.

By your own admission there are not enough PCPs. So simply paying the current ones more won't do anything to solve the lack of PCPs, will it?

 

[MOHS_01]

Thanks for being a good guy MOHS:

You saying "lesser quality yet deliver greater results?" Ok, first off, we're comparing primary care to dermatology, there's no doubt that primary care is more "cost effective" and certainly "appropriate". But I'm glad you were able to string all those pieces together. And "insulting to PCPs everywhere", not at all actually. Students aren't choosing dermatology over primary care because of the wide array of cases they get to see, it's the compensation. I don't think many people would argue that to get a derm residency you have to have top board scores correct? I also don't think many would argue that because of compensation primary care has become less competitive, ie lower board scores. Does this mean ALL PCPs are of lower quality, only if you assume everyone is as money hungry as I'm sure 80% of your derm buddies are. That damn ACA, trying to recruit more students into primary care by increasing compensation, they must think they're all stupid right? You tell me though, if compensation is increased do you not think we would have less IMGs able to match into primary care and more US grads that do, does this not increase quality?

:cry:


Strong, effective, reasoned argument right there, champ. Riddled with sound reasoning backed by convincing data -- how can one refute brilliant and incisive arguments like those? The 80% of dermies was just the cherry on top...

Less IMG's =/= increased quality, necessarily and by definition, btw. It may or it may not, who knows -- but you're conflating a variety of topics that should be discussed individually.

 

[DrAwsome]

No more PCPs = no additional access.

 

[MedicineDoc]

By your own admission there are not enough PCPs. So simply paying the current ones more won't do anything to solve the lack of PCPs, will it?

So I think we agree that MORE primary care providers are needed, right? So you can increase primary care doctors OR midlevels.

It makes A LOT more sense to have PCPs supervise NP/PAs who get paid roughly half of what PCPs get paid, so that more patients can be seen at a lower cost. Works for anesthesia. I don't see why it would not work for primary care.

Having more midlevels being supervised by a PCP is more cost effective, it gets the job done, it allows more people to have care and hopefully prevent more serious and expensive health issues, it is obviously cheaper than paying PCPs more, and it is cheaper than having more funding for residency positions.

Do you disagree with me still?

I haven't seen anything good come out of midlevel involvement in medicine. Supervising and fixing bad care is more time consuming than seeing the same number of patients and doing right in the first place yourself. It is the people who are willing to sign off on bad care that make money on midlevels. That's my honest opinion from observing midlevels in both specialty and primary care and believe me there are alot of midlevels in specialty medicine.

 

[DrAwsome]

I haven't seen anything good come out of midlevel involvement in medicine. Supervising and fixing bad care is more time consuming than seeing the same number of patients and doing right in the first place yourself. It is the people who are willing to sign off on bad care that make money on midlevels. That's my honest opinion from observing midlevels in both specialty and primary care and believe me there are alot of midlevels in specialty medicine.

So in your opinion, midlevels provide poor care? And according the "burger" above, IMGs in primary care also provide poor care. so then we are left with only AMGs then filling primary care spots?

Well then you need to massively increase residency positions in addition to paying PCPs slightly more? That would cost a tremendous amount of $$. It would also take about a long time for new AMGs to get into these positions.

I also doubt that it would lead to significantly better outcomes. And as I said above from a financial perspective, I think it would be death.

 

[MedicineDoc]

So in your opinion, midlevels provide poor care? And according the "burger" above, IMGs in primary care also provide poor care. so then we are left with only AMGs then filling primary care spots?

Well then you need to massively increase residency positions in addition to paying PCPs slightly more? That would cost a tremendous amount of $$. It would also take about a long time for new AMGs to get into these positions.

I also doubt that it would lead to significantly better outcomes. And as I said above from a financial perspective, I think it would be death.

Enough of the ridiculous circular questioning and assertions. Trolling is all it is. What specialty are you involved with?

 

[MedicineDoc]

From you post history it appears you just matched several months ago. Fresh out of medschool.

 

[MedicineDoc]

Oh, sorry -- missed that gem. Skin cancer is rather unique, actually. It is one of the reasons I do what I do, by the way. If you're good at it -- which some are, but many are not -- it can be hugely cost effective. Why? Because of the unique exposed nature of the skin and the piss poor reimbursement for E&M services, that's why. You can catch it when it is cheap and easy to cure with a relatively cheap and simple surgery. No expensive chemo (which does not work). No expensive radiation (which does not work very well). No hospitalizations (well, for the vast, vast majority).

If building strawmen were a marketable skill you'd be cashed out and running for Prez....

SMH. If you are going to form an argument, the very least you can do is make an effort to understand it. Saying that something is "cost effective" is making a quantifiable statement; it says nothing about whether it "should" or "should not" be undertaken. Things can be cost effective and not the most appropriate -- and some things not demonstrably cost effective can still be deemed appropriate. This is not a terribly difficult concept to grasp -- assuming you're willing to think just a little bit.

Many screenings -- and much of preventative care -- when rendered in a one on one fashion in a providers office is not cost effective across a population. More money will be spent in doing so than saved by doing so. There have been a variety pilot projects that have demonstrably failed to provide cost savings -- despite what the technocrats promised. This -- again -- is not to say that they are not worthwhile or should not be done -- just that money is not being saved in aggregate by doing so. Follow?

Since you asked about micrographic surgery -- a couple of finer points for my ill informed colleague. Yes, it has been shown time and again to be demonstrably cost effective for appropriately selected tumors. It does save money in aggregate. The cost effective benefits have been increased with recent Medicare coverage criteria, fee schedule changes, and the loss of the multiple procedure reduction exemption. Your ignorant envy aside, there is a reason that even HMO's and tightly controlled state agencies such as the VA outsource more now than in years past.

T:

Oh so skin cancer surveillance is unique and cost effective but lowering blood pressure doesn't decrease mortality by decreasing CAD, PVD, strokes, LVH, CHF, CKD, afib and keeping diabetes under control doesn't reduce amputations, infections, DIabetic nephropathy, number of people requiring dialysis, Diabetic retinopathy and having primary care providers doesn't prevent hospitalizations and reduce admission rates. Patients with COPD exacerbations should just wait until they cant move any air and go to the hospital rather than getting steroid tapers and antibiotics from their primary. Smoking cessation counseling prescriptions are a waste of money and better dealt with in the hospital. Asthmatics don't really need to be on maintenance medications based on the severity of their asthma. It's better just to wait until diabetics get gangrene and cut their limbs off. People with CHF are better dealt with in the hospital rather than adjusting their lasix and monitoring their kidney function on diuretics as an outpatient. All people with Afib should go directly to the hospital rather than getting anticoagulation and rate control adjustments as an outpatient. Nobody needs to make sure stroke patients are on adpirin or plavix or people with stents less than a yr old are still taking their plavix. Noone needs to check meds prescribed by multiple specialist for drug interactions such as multiple drugs that can cause rhabdo. We should just let the nurse practitioners prescribe random bp meds that don't make any sense or are dangerous together. We should just let ER docs give CT scans of the head and admit people with BPPV for syncope with neuro and cardiology consults. People with knee effusions should go directly to an orthopedic surgeon. Ingrown toenails should be seen only by plastic surgeons. All high school kids with acne need a dermatologist. All patients on thyroid medicine should be seeing an endocrinologist.

You really are living in a completely derm world. I think you are so far into it it would be dangerous for you to try to manage a medical case other than strict derm.

 

[deleted87716]

"If you have a new health insurance plan or insurance policy beginning on or after September 23, 2010, the following preventive services must be covered without your having to pay a copayment or co-insurance or meet your deductible."

Ouch

No "ouch."

If Medicare reimburses $100 for a hypothetical preventive service, the physician will still get $100 when they bill Medicare. It's just that none of it is paid directly by the patient. Theoretically, this is intended to help encourage patients to have recommended preventive services.

 

[deleted4401]

Based on these posts, it appears that the some of the future PCPs don't have very good English reading, writing, and rhetorical skills

What the dermatologist was saying is that screening is not always cost-effective. A great example is prostate cancer. If you screen for it, you'll find it, and generally it will get treated at a very high cost. If you don't screen for it, you only have to treat those that are symptomatic. More people will die that way, but this is an example of how screening is NOT cost effective.

This idea that I'm responsible for what happens upstream is sort of unfair. If a cervical cancer or head and neck cancer patient comes to me, we treat it and aim for cure. Why is it my fault that they got cancer in the first place and why should I get a lesser salary because someone else didn't do the screening? I'm in therapeutics, not diagnostics/prevention.

Anyway, like others, I'll bow out. People aren't engaging in the questions or utilizing logic. PCP pay is low for a host of reasons. Certain specialists are paid well for a host of reasons. I'm not sure if re-distribution is the best method to achieve better health goals, although it may make certain people feel better. We should run medicine more efficiently with efficacy and cost as goals 1 and 1A. Outcomes will be better, profits will be higher. No need to go all Robin Hood on the specialists.

But, I'm still wondering, how much do you think I should make if I'm the most grossly overpaid type of specialist (along with the dermatologists)? How much more or less should I make than the cardiologist or orthopedist or the anesthesiologist or the family practictioner? Why? What if an FP is in a small, but wealthy suburban town and does a lot of cosmetics and outearns me? Should we reduce her income? How about an internist that does joint injections and dispenses pharmaceuticals/supplements that outearns the the local nephrologist? Should we restrict their income, too? It's a slippery slope when Peter robs Paul, because (Uncle) Sam is the one that ends up with all the money in the end.

-S

 

[MOHS_01]

Oh so skin cancer surveillance is unique and cost effective but lowering blood pressure doesn't decrease mortality by decreasing CAD, PVD, strokes, LVH, CHF, CKD, afib and keeping diabetes under control doesn't reduce amputations, infections, DIabetic nephropathy, number of people requiring dialysis, Diabetic retinopathy and having primary care providers doesn't prevent hospitalizations and reduce admission rates. Patients with COPD exacerbations should just wait until they cant move any air and go to the hospital rather than getting steroid tapers and antibiotics from their primary. Smoking cessation counseling prescriptions are a waste of money and better dealt with in the hospital. Asthmatics don't really need to be on maintenance medications based on the severity of their asthma. It's better just to wait until diabetics get gangrene and cut their limbs off. People with CHF are better dealt with in the hospital rather than adjusting their lasix and monitoring their kidney function on diuretics as an outpatient. All people with Afib should go directly to the hospital rather than getting anticoagulation and rate control adjustments as an outpatient. Nobody needs to make sure stroke patients are on adpirin or plavix or people with stents less than a yr old are still taking their plavix. Noone needs to check meds prescribed by multiple specialist for drug interactions such as multiple drugs that can cause rhabdo. We should just let the nurse practitioners prescribe random bp meds that don't make any sense or are dangerous together. We should just let ER docs give CT scans of the head and admit people with BPPV for syncope with neuro and cardiology consults. People with knee effusions should go directly to an orthopedic surgeon. Ingrown toenails should be seen only by plastic surgeons. All high school kids with acne need a dermatologist. All patients on thyroid medicine should be seeing an endocrinologist.

You really are living in a completely derm world. I think you are so far into it it would be dangerous for you to try to manage a medical case other than strict derm.

*sigh*

I tried to use small words and easy to digest thoughts for you. Obviously that was not enough. Let's try this again:

Yes, skin cancer is rather unique given its high prevalence and low cost of screening. It takes the combination of the two to make it cost effective. If you screen every person, even at this significant advantage, even it is not cost effective. This is wholly different from saying that it should not be done.

Words mean things, doctor. When you say "cost effective" it means something in particular -- that, in by providing said service, it decreases total expenditures over X amount of time. Changing the oil in your car is cost effective. Screening targeted populations may be cost effective. Much of what we do is not. It may be cost effective for the individual to have their insurance pay for x, y, or z -- but that is not the same thing as saying intervention x, y, or z is cost effective in aggregate for a general population.

In the event that you missed it the first four times it was stated -- this is not an argument for or against any given intervention. I do not believe in the absolute authority of means testing nor cost efficacy criteria. Should you want to be a cost efficacy purist, chew on this for a second -- the most cost effective treatment would be no treatment at all -- the cheapest healthcare system is the one that does not treat. Now most rational people understand that this is not ideal, but....

Helluva string of strawmen there, though. You had your own little strawman army.

 

[MOHS_01]

No "ouch."

If Medicare reimburses $100 for a hypothetical preventive service, the physician will still get $100 when they bill Medicare. It's just that none of it is paid directly by the patient. Theoretically, this is intended to help encourage patients to have recommended preventive services.

It also means that all of these "preventative services" are accounted and paid for up front through the premium -- whether they are utilized or not... yet, somehow, the ACA proponents are billing this as "free". Odd dictionary they use. Odd indeed.

 

[MedicineDoc]

*sigh*

I tried to use small words and easy to digest thoughts for you. Obviously that was not enough. Let's try this again:

Oh, I get it. Specialist = smart. Primary care physician = dumb. Truthfully, I would be too bored taking care of one organ system on a career long basis no matter what it paid.

 

[MOHS_01]

Oh, I get it. Specialist = smart. Primary care physician = dumb. Truthfully, I would be too bored taking care of one organ system on a career long basis no matter what it paid.

Go here.

 

[MedicineDoc]

I know what a straw man is I took logic class in college and made an almost perfect score if I remember correctly. Are you denying that there aren't enough primary care physicians, they aren't paid enough, or that they are the most essential part of the health care system?

 

[Smokemont]

You should call around to your local family physicians and tell them you are a medicaid patient and see how many appointments you can get. I'm guessing not many. Why? Because FM docs actually lose money when seeing these patients (based on those I've talked to). The logic here would tell us that by paying PCPs more money you can increase access. I'm not saying this would fix the problem, but it could help. Unless I am missing something, in which case please educate me.

I just wanted to repost this because I feel it was a valid point and no one responded to it.

 

[bigkahunaburger]

drawesome has a knack for skipping over things that poke holes in her argument

 

[DrAwsome]

Enough of the ridiculous circular questioning and assertions. Trolling is all it is. What specialty are you involved with?

The only one trolling is you. All you can do is repeat the same thing "PCPs need to be paid more." Yet you lack any type of insight or explanatory ability to inform the rest of us how paying more to these docs will solve anything.

You lack critical thinking skills, and are now getting upset for being challenged. Premeds think they know it all, when they are clueless.

Since you continue to insist on ridiculous claims with no ability to provide any logical basis, I'm going to propose we pay specialists more, and pay PCPs less.

 

[DrAwsome]

I just wanted to repost this because I feel it was a valid point and no one responded to it.

Not surprisingly, even if all patients had insurance, they still would not be able to get care because of lack of PCPs.

 

[DrAwsome]

I know what a straw man is I took logic class in college and made an almost perfect score if I remember correctly. Are you denying that there aren't enough primary care physicians, they aren't paid enough, or that they are the most essential part of the health care system?

Get it straight-there are not enough PCPS-I have said this only about a million times, but your fellow posters such as burger continue to skip over this factoid.

 

[DrAwsome]

From you post history it appears you just matched several months ago. Fresh out of medschool.

As I said, you lack not just critical thinking skills but also attention to detail. If you cared to pay any attention and do even a minor search, you'd realize that I'm switching from derm to rad onc, so no, you are wrong.

 

[DrAwsome]

Based on these posts, it appears that the some of the future PCPs don't have very good English reading, writing, and rhetorical skills

What the dermatologist was saying is that screening is not always cost-effective. A great example is prostate cancer. If you screen for it, you'll find it, and generally it will get treated at a very high cost. If you don't screen for it, you only have to treat those that are symptomatic. More people will die that way, but this is an example of how screening is NOT cost effective.

This idea that I'm responsible for what happens upstream is sort of unfair. If a cervical cancer or head and neck cancer patient comes to me, we treat it and aim for cure. Why is it my fault that they got cancer in the first place and why should I get a lesser salary because someone else didn't do the screening? I'm in therapeutics, not diagnostics/prevention.

Anyway, like others, I'll bow out. People aren't engaging in the questions or utilizing logic. PCP pay is low for a host of reasons. Certain specialists are paid well for a host of reasons. I'm not sure if re-distribution is the best method to achieve better health goals, although it may make certain people feel better. We should run medicine more efficiently with efficacy and cost as goals 1 and 1A. Outcomes will be better, profits will be higher. No need to go all Robin Hood on the specialists.

But, I'm still wondering, how much do you think I should make if I'm the most grossly overpaid type of specialist (along with the dermatologists)? How much more or less should I make than the cardiologist or orthopedist or the anesthesiologist or the family practictioner? Why? What if an FP is in a small, but wealthy suburban town and does a lot of cosmetics and outearns me? Should we reduce her income? How about an internist that does joint injections and dispenses pharmaceuticals/supplements that outearns the the local nephrologist? Should we restrict their income, too? It's a slippery slope when Peter robs Paul, because (Uncle) Sam is the one that ends up with all the money in the end.

-S

Again well said. As you have pointed out, people do not want to engage in the questions posed. And simply put, people just want to equate PCP = good/saint, specialist = evil.

I guess I am doubly evil, haha.

 

[Smokemont]

Not surprisingly, even if all patients had insurance, they still would not be able to get care because of lack of PCPs. Maybe you are unable to see that or simply can't think about reality here. Oh well.

I have addressed it as well, so maybe you should look at the threads first.

I think you should probably tone down your holier than thou attitude. I posted a very realistic situation that a 'resident' should be aware of.

So a couple of things. Realistically, how much do you think primary care docs should make? I think 200k for a 3 year residency, particularly if you are a hospital employee and you see 15-20 patients per day is a good amount of money. More than that seems a little excessive for the work in and out daily, and for the training required.

So let's say we pay PCPs 200k and they are mostly hospital employees, so all they have to worry about is seeing patients and don't have to worry about their payments, medicare, etc. Ok. Hopefully they are happier and feel better compensated. So now what? We still have millions of new patients that now want care, medicare or not.

Remember, PCPs now being hospital employes and making 200k only really have to worry about is being in the hospital and treating patients. But wait-we still don't have enough PCPs to treat all the millions of new people that have been added to the system.

You are not really increasing access because there are still millions of new patients that need to be seen, with not enough PCPs to go around. So access is still limited.

Even if everyone had insurance that paid a normal rate, there would not be enough PCPs to go around treating all these millions of new people. So now we've created a new system where PCPs are making more $ than they were before, but we still have a ton of patients that need care with not enough manpower/supply of PCPs to treat them.

So access is still restricted.

Manpower one way or another needs to be increased. We can increase primary care doctor residencies to cover the increased millions of new patients or have midlevels take up some of that slack.

You, in no way, addressed my point. So maybe you should re-read it. You turned the situation into a hospital employee that, and I quote, " all they have to worry about is seeing patients and don't have to worry about their payments, medicare, etc." when I was specifically talking about a PCP that can't afford to see Medicaid (you said Medicare) because their operating costs outweigh the low reimbursement. I said nothing about the amount of PCPs but did acknowledge that my point was not a fix. As you have said, most (if not all) FM residency spots get filled. So what's the problem with access? The problem is likely the distribution of where PCPs choose to practice. So the logical solution would be to provide incentive for PCPs to practice in less desired locations. Incentive for work? What does that mean? How about we pay them more (or forgive loans) to practice in the underserved areas?

 

[MedicineDoc]

Again well said. As you have pointed out, people do not want to engage in the questions posed. And simply put, people just want to equate PCP = good/saint, specialist = evil.

I guess I am doubly evil, haha.

Try a stupid sdn troll who clutters up threads repeating the same idiotic assertions and "questions" over and over again. It must be the excellent people skills you picked up in your patient interactions in dermatopathology.

 

[Smokemont]

200k is MORE than enough for a PCP. Many make more than that, so they are paid more than they should already.

There are not enough PCPS-I have said this only about a million times, but your fellow posters such as burger continue to skip over this factoid.

I disagree that they are the most essential part of the health care system. I think their role can be done in a much more cost effective way by midlevels.

You may think about what it is that PCPs do, and realize that a lot of that work can be done much much cheaper and efficiently by having more midlevels.

This just blows my mind. So you think that we're just all brainwashed into thinking this?

 

[MOHS_01]

I just wanted to repost this because I feel it was a valid point and no one responded to it.

You should call around to your local family physicians and tell them you are a medicaid patient and see how many appointments you can get. I'm guessing not many. Why? Because FM docs actually lose money when seeing these patients (based on those I've talked to). The logic here would tell us that by paying PCPs more money you can increase access. I'm not saying this would fix the problem, but it could help. Unless I am missing something, in which case please educate me.

PS - I don't think specialists are overpaid and do not support taking money from them, at least not too much

Do you believe that the situation described is somehow unique to FP's?

 

[MOHS_01]

200k is MORE than enough for a PCP. Many make more than that, so they are paid more than they should already.
....

What kind of BS is this? It's because of nonsense like this that the entire discussion is poisoned. It's not as if we are somehow granted an income of X -- we earn it in a unit labor fashion after feeding every other mouth at the trough. Who are you -- or anyone, for that matter -- to say that the person who works harder, smarter, or longer should earn X, Y, or Z? You're not helping anyone's cause by taking this line of reasoning.... and midlevels can more cheaply provide many services that any given specialty provides -- it's not unique to primary care.

 

[Smokemont]

Do you believe that the situation described is somehow unique to FP's?

Not at all. I just thought it would represent a situation where increasing salary (medicaid reimbursement) could increase access. Members of my family have experienced wait times of several months, mainly for derm. I think we can all agree that the system is broken, hopefully even if you are making 500k. I do not believe that decreasing specialists salaries or increasing midlevel responsibility is part of the answer. But I do believe that primary care is the most important part of a health care system. I am NOT saying that PCPs are more important than specialists, there is a difference.

 

[MOHS_01]

This just blows my mind. So you think that we're just all brainwashed into thinking this?

Well, actually, yeah, I do. Important role? Most definitely. "Most essential"? Meh..... Foundational role? Yes. Single-most-important-thing-under-the-God-given-sun-above? Is the foundation truly more important than anything and everything that rests upon it? That is where this line of reasoning falls apart, the ipso facto assignment of importance to the nebulous prime imperative that is the current primary care initiative. It flies in the face of the balance of modern societal organization and ignores the long recognized efficiencies afforded by the division of labor. Now saying so constitutes blasphemy in many circles -- a curious phenomenon when discussing matters among the allegedly critical and scientific, something most often reserved for matters of the religious.... well, come to think about it, that brings us full circle now, doesn't it.

 

[MedicineDoc]

I would believe that if midlevels made midlevel salaries. When you are paying them the same, then you are getting worse outcomes with same salaries, which is a recipe for disaster. Sadly many people being seen by midlevels end up in doctor offices.

What's the point of paying a PA 150k and an FP doctor the same? How does that curtail salaries?

Reducing staff/administrator salaries, reducing nursing salaries, having midlevels have midlevel salaries, not extending end of life care for the 98 year old who has PNA, sepsis, and dementia, are all ways to keep costs in check. I've had patients who were 99! and were getting PT ordered! I had a patient who was 96 getting a PEG tube. Seriously?

When you have nurses making 100k, and PA's making 150k, it's not very cost effective, is it?

Are you thinking of specializing or straight IM? Primary care IM can be tough. I've always liked heme/onc but have always thought that I could never deal with an ICU month so never went to for it. Psych is still IMG friendly and has a great lifestyle. With that said, yes med school admissions are increasing tremendously and will get more difficult to find spots in future years. Can you search for another spot while still keeping your current one?

I don't think you are understanding my point. Having PA/NP's get paid the same as FP's for example will inevitably lower people going into FP because it doesn't make any sense. So if there are GP shortages, you pay them less, while paying midlevels more than you? That makes no sense. Why would anyone go into PC when you can do it with much less education and liability for same pay!?

http://forums.studentdoctor.net/showpost.php?p=12849393&postcount=45

 

[MOHS_01]

Not at all. I just thought it would represent a situation where increasing salary (medicaid reimbursement) could increase access. Members of my family have experienced wait times of several months, mainly for derm. I think we can all agree that the system is broken, hopefully even if you are making 500k. I do not believe that decreasing specialists salaries or increasing midlevel responsibility is part of the answer. But I do believe that primary care is the most important part of a health care system. I am NOT saying that PCPs are more important than specialists, there is a difference.

Fair enough. Can you help me just a little, though? How can you reconcile the two bolded statements? "Most" assigns a position of superiority in a given hierarchical / ordinal set (at least for most of us) Or is this an example of all animals are equal, just some are more equal than others?

I honestly believe much of the underpinnings of medical student thoughts on the matter of pay discrepancies lies in no small part with their fundamental misunderstanding of the actual pay construct upon practice. For the most part, we are not salaried individuals. We work in a piecemeal manner and are paid according to this. The CPT system is fraught with problems, but one thing that it does well is that it appropriately rewards the laborer providing care to 10 people more than it does the one providing equivalent care to 3.

 

[deleted87716]

It also means that all of these "preventative services" are accounted and paid for up front through the premium -- whether they are utilized or not... yet, somehow, the ACA proponents are billing this as "free". Odd dictionary they use. Odd indeed.

Healthcare in Canada is free, too.

 

[DrAwsome]

I think you should probably tone down your holier than thou attitude. I posted a very realistic situation that a 'resident' should be aware of.



You, in no way, addressed my point. So maybe you should re-read it. You turned the situation into a hospital employee that, and I quote, " all they have to worry about is seeing patients and don't have to worry about their payments, medicare, etc." when I was specifically talking about a PCP that can't afford to see Medicaid (you said Medicare) because their operating costs outweigh the low reimbursement. I said nothing about the amount of PCPs but did acknowledge that my point was not a fix. As you have said, most (if not all) FM residency spots get filled. So what's the problem with access? The problem is likely the distribution of where PCPs choose to practice. So the logical solution would be to provide incentive for PCPs to practice in less desired locations. Incentive for work? What does that mean? How about we pay them more (or forgive loans) to practice in the underserved areas?

Well if the PCPs worked for the hospitals, as is it the trend now, that most doctors are choosing hospital vs private practice, it is a moot point. Hospital docs don't have to worry about insurance payments or anything of the sort.

As you point out, YOU SAID NOTHING ABOUT THE AMOUNT OF PCPS which is EXACTLY MY POINT!!! The lack of PCPs is ultimately what leads to LACK OF ACCESS - it's a simple freaking point. Not enough PCPS, NOT ENOUGH ACCESS.

Also you are a naive, ignorant medical student. Don't use quotes- I'm actually a resident, and a resident going from one of the most competitive specialties to another of the most competitive specialties that there are, so I think I know a thing or two.

Learn to be humble and learn from others who can teach you something.

 

[DrAwsome]

This just blows my mind. So you think that we're just all brainwashed into thinking this?

I don't know what you think. Since you live in America, I assume, you are free to think what you'd like. *I* however don't feel primary care doctors are the most important part of the healthcare system. *You* however are free to disagree.

 

[MOHS_01]

Healthcare in Canada is free, too.

Oh snap!!! I forgot all about that. Do you think those Canadian dictionaries somehow got mixed up with ours here in the States? You know, like those darn Canadian coins?

 

[Smokemont]

Well, actually, yeah, I do. Important role? Most definitely. "Most essential"? Meh..... Foundational role? Yes. Single-most-important-thing-under-the-God-given-sun-above? Is the foundation truly more important than anything and everything that rests upon it? That is where this line of reasoning falls apart, the ipso facto assignment of importance to the nebulous prime imperative that is the current primary care initiative. It flies in the face of the balance of modern societal organization and ignores the long recognized efficiencies afforded by the division of labor. Now saying so constitutes blasphemy in many circles -- a curious phenomenon when discussing matters among the allegedly critical and scientific, something most often reserved for matters of the religious.... well, come to think about it, that brings us full circle now, doesn't it.

Fair enough. Can you help me just a little, though? How can you reconcile the two bolded statements? "Most" assigns a position of superiority in a given hierarchical / ordinal set (at least for most of us) Or is this an example of all animals are equal, just some are more equal than others?

I honestly believe much of the underpinnings of medical student thoughts on the matter of pay discrepancies lies in no small part with their fundamental misunderstanding of the actual pay construct upon practice. For the most part, we are not salaried individuals. We work in a piecemeal manner and are paid according to this. The CPT system is fraught with problems, but one thing that it does well is that it appropriately rewards the laborer providing care to 10 people more than it does the one providing equivalent care to 3.

I see what you're saying for the most part but I won't pretend like I understand everything. How do I reconcile? Coordination of care and organization. For example, from my limited knowledge, I support the medical home model. Care should start with the PCP, who then decides what specialties need to be involved. Patients shouldn't be deciding who they need to see, tests/scans shouldn't need to be repeated, paperwork shouldn't have to be filled out multiple times etc. This is why I said it is the most important part of the system. Perhaps I'm wrong, I can only go off my limited experience. I am on these boards to learn from those with more wisdom and give back to those with less.

 

[DrAwsome]

Try a stupid sdn troll who clutters up threads repeating the same idiotic assertions and "questions" over and over again. It must be the excellent people skills you picked up in your patient interactions in dermatopathology.

So now you are simply being abusive, so I will be reporting you to abuse. you don't call me stupid, not today, not tomorrow, not ever. I can and will post as I feel is appropriate, just like you do.

Who are you to reply but I can't? I suggest you really lower your tone and change your attitude. And if you can't have a rational conversation wihtout going into insane mode, then you should get out of medicine quickly if you don't want to find yourself fired quickly.

 

[MOHS_01]

I know what a straw man is I took logic class in college and made an almost perfect score if I remember correctly. Are you denying that there aren't enough primary care physicians, they aren't paid enough, or that they are the most essential part of the health care system?

Huh. Please tell me the name of this school (so that my children are sure to never attend). There may not be enough PCPs -- how does their average wait time for a visit compare to other specialties? I would like to see them paid better. Most essential...

 

[MOHS_01]

I see what you're saying for the most part but I won't pretend like I understand everything. How do I reconcile? Coordination of care and organization. For example, from my limited knowledge, I support the medical home model. Care should start with the PCP, who then decides what specialties need to be involved. Patients shouldn't be deciding who they need to see, tests/scans shouldn't need to be repeated, paperwork shouldn't have to be filled out multiple times etc. This is why I said it is the most important part of the system. Perhaps I'm wrong, I can only go off my limited experience. I am on these boards to learn from those with more wisdom and give back to those with less.

You see, that's reasonable. I too am a fan of the medical home model. Gotta run, taking the kids to swimming lessons -- but I'm with you on most of this.

MD -- that is how you have a discussion.

 

[bronx43]

Well if the PCPs worked for the hospitals, as is it the trend now, that most doctors are choosing hospital vs private practice, it is a moot point. Hospital docs don't have to worry about insurance payments or anything of the sort.

As you point out, YOU SAID NOTHING ABOUT THE AMOUNT OF PCPS which is EXACTLY MY POINT!!! The lack of PCPs is ultimately what leads to LACK OF ACCESS - it's a simple freaking point. Not enough PCPS, NOT ENOUGH ACCESS.

Also you are a naive, ignorant medical student. Don't use quotes- I'm actually a resident, and a resident going from one of the most competitive specialties to another of the most competitive specialties that there are, so I think I know a thing or two.

Learn to be humble and learn from others who can teach you something.

This chick is hilarious. I pretty much had to read that last part like three times to make sure I wasn't missing any epic sarcasm. I wasn't.

 

[MedicineDoc]

So now you are simply being abusive, so I will be reporting you to abuse. you don't call me stupid, not today, not tomorrow, not ever. I can and will post as I feel is appropriate, just like you do.

Who are you to reply but I can't? I suggest you really lower your tone and change your attitude. And if you can't have a rational conversation wihtout going into insane mode, then you should get out of medicine quickly if you don't want to find yourself fired quickly.

The moderator has already warned you in this thread about trolling specifically telling you that coming into a specialties forum and stating that midlevels could do their job just as well is considered trolling all of which are underlined by your past contradictory statements I posted above from previous threads.

 

[Smokemont]

Well if the PCPs worked for the hospitals, as is it the trend now, that most doctors are choosing hospital vs private practice, it is a moot point. Hospital docs don't have to worry about insurance payments or anything of the sort.

As you point out, YOU SAID NOTHING ABOUT THE AMOUNT OF PCPS which is EXACTLY MY POINT!!! The lack of PCPs is ultimately what leads to LACK OF ACCESS - it's a simple freaking point. Not enough PCPS, NOT ENOUGH ACCESS.

Also you are a naive, ignorant medical student. Don't use quotes- I'm actually a resident, and a resident going from one of the most competitive specialties to another of the most competitive specialties that there are, so I think I know a thing or two.

Learn to be humble and learn from others who can teach you something.

1. No one said anything about PCPs working for hospitals. My situation was regarding PCPs who do have to worry about insurance payments. So it is not a moot point, it is a valid point.

2. I addressed your main point - the amount of PCPs. Financial incentive to distribute PCPs in areas of need to increase access. Can't you just have a rational discussion.

3. A naive and ignorant medical student? Fair enough, I don't take that as an insult, even if you meant it that way.

4. Congratulations on all your success. I hope you enjoy rad onc more than you apparently enjoyed derm. If not, we could always use more family physicians .

5. Be humble and learn from others? Oh I consider myself very good at that, but you don't make it easy. I have never said anything to offend or challenge your experience (the quotes around resident were not meant to offend). You seem to be channeling your anger from other posters to me.

 

[DrAwsome]

The moderator has already warned you in this thread about trolling specifically telling you that coming into a specialties forum and stating that midlevels could do their job just as well is considered trolling all of which are underlined by your past contradictory statements I posted above from previous threads.

I amnot saying anything pejorative about PCPs. I am voicing my thoughts that it is more cost efficient to have midlevels. If anything you and burger have suggested that current PCPs suck, I have not. So stop trolling. either have a normal discussion or get out of the forum.