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More patients? Higher taxes? Physician payment? More medicade but slightly higher payments? Medicare? More mid levels?
Obamacare and Obama net plus or minus for primary care physicians?
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There are a lot of statements comments about "DO NOT go into Family Practice" floating around EVERYWHERE. . .not just SDN. After this election, is this more of a given than ever?
Seems like the only impetus going forward, at least economically, for going into FP would be for NP's. As my professor intimated a while back, perhaps that is really what is wanted from governmental administrative powers in order to facilitate "more coverage" for less money--as it would be directed by governmental administrative influences. People never seem to get that money has to come from somewhere. Getting stuff means taking stuff from other people. It amazes me that people don't get this reality. People actually do think there is such a thing as free lunches--as if they fell with rainbow balloons from the sky.
Thus, if it is true that the powers that be want to push the health reform changes, they have to find a way to make the cost stretch, and that would mean flooding of NPs. So, becoming a FP for many physicians, at least financially, would be a dead end field.
I hope I am wrong, but I have a very sick, sinking feeling in my gut about this.
The exception may be if they give a huge break on medical school loans for those going into family medicine. But even that isn't cheaper than employing NPs to rule in family medicine.
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I think the future is only going to get better for FM. Pay should go up modestly (as specialist pay heads lower). Demand for FM will be huge as more pts have access to heathcare. Will mid-levels prosper as well? Sure they will, but you will still need FM doc's versitility and knowledge base particularly in underserved areas.
Now if you are wanting to be a 8-5 outpt only doc, things may not be as good (but still not bad). But the more you are able to do (i.e. colpos, Leeps, OB, scopes...) the more in demand you will be. Think about it; what would be more economical than a full scope FM doc? Talk about bang for your buck! NPs, PAs can't provide that. No other specilaty can offer this kind of versitility.
FM is in the position to become THE specialty of the future!
Now if you are wanting to be a 8-5 outpt only doc, things may not be as good (but still not bad). But the more you are able to do (i.e. colpos, Leeps, OB, scopes...) the more in demand you will be. Think about it; what would be more economical than a full scope FM doc? Talk about bang for your buck! NPs, PAs can't provide that. No other specilaty can offer this kind of versitility.
FM is in the position to become THE specialty of the future!
I think you dream kdur. Some reimbursement may up slightly, but people are going to be busting hump to fit in a lot, and overall the reimbursements will be minimal comparatively when looking at the time invested. But for NPs, it may be more beneficial. For physicians, I don't think so. The big exception to this is if they seriously cut the the medical school and income loss load on FP physicians.
What you also must figure is that the more you open yourself to such procedures above, as well as definitely OB, the greater you malpractice insurance fee coverage will be. Any procedure that is invasive in nature increases risk and potential liability.
True, but as a hospital employed physician your malpractice is covered by the institution. Having your own practice and doing it all yourself is becoming more and more a thing of the past.
Additionally there are increases in loan repayment/forgiveness options available to primary care physicians who practice high need areas.
As we look toward the future the focus will be on the PCMH, and prevention. The era of the generalist is upon us. Both MD/DO and mid-levels will have plenty of work. But don't think for a minute that we will be replaced. Because in the end when someone is given a choice for their healthcare they will choose a physician almost everytime.
Additionally there are increases in loan repayment/forgiveness options available to primary care physicians who practice high need areas.
As we look toward the future the focus will be on the PCMH, and prevention. The era of the generalist is upon us. Both MD/DO and mid-levels will have plenty of work. But don't think for a minute that we will be replaced. Because in the end when someone is given a choice for their healthcare they will choose a physician almost everytime.
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As a hospital employed physician. . .hmm. . .
"A recent survey by the Doctor Patient Medical Association Foundation reveals that 83 percent of physicians surveyed are thinking of quitting because of Obamacare, and 90 percent feel that the U.S. health care system is now heading in the wrong direction.
This result is not a surprise; patients everywhere need to be concerned that Obamacare is putting an enormous new weight on the back of doctors who were already over-burdened."
I further quote the following from "Will Your Doctor Quit? Obamacare Foretells Mass Exodus From Patient Care":
{Will doctors actually quit or just become more and more unhappy and dysfunctional? Most of us are locked into a career and a lifestyle that we cant change. We have trained for many years to get to this point. Instead of quitting, most of us will continue to struggle along with the rising Obamacare regulations and restrictions with over a hundred new federal agencies and thirty-three new regulatory committees. We will accept lower incomes amid rising expenses while spending less and less time with our patients because frankly we have no other choice.}
http://www.forbes.com/sites/marcsie...care-foretells-mass-exodus-from-patient-care/
Also, consider that you are really talking hospitalists, of whom now, there are only around 7000 in the US. Now, of those covered by the hospital, as the employer, a larger percentage of those are "in-house" (institutional-based) self-insured plans.
[Fully Insured or Self Insured?
Malpractice policies available through employers are either fully insured or self insured. The difference between the two types involves who is responsible for the claims payouts. With fully insured plans, the employer pays a premium to an insurer and the insurer pays claims out of the pool of premiums it collects from everyone it insures. Under a self-insured plan, the employer is responsible for paying all claims out of company assets. The Employee Retirement Income Security Act (ERISA) regulates self-insured plans; the plans are then under the jurisdiction of the U.S. Department of Labor.
The hospitalists that we do [under]write [fully insured policies] for tend to be in the smaller community hospitals, which may not necessarily have the huge need for hospitalists; whereas the larger institutions may have a larger need for hospitalists [and] they usually tend to be self-insured, says Zorola.]
http://www.the-hospitalist.org/details/article/255607/A_Malpractice_Primer_.html
You may not be thrilled with the parameters under which the self-insured plan of the hospital covers you.
Again, any time you DO ANYTHING INVASIVE, and OB would certainly fall under this as well, you increase risk and liability. There is a curve of learning, and you must do a lot of these procedures on a regular basis. It's a double-edge sword to some degree, b/c you have to do many and do so well with the right guidance and supervision in order to statistically make it worth your while to do such procedures--from the patient's perspective and from a financial one on your end. However, by doing more, and more on a regular basis, you increase the stastically probability of error, risk, and liability.
This is why, in my view, a lot of general practitioner or FP's people do not engage in these procedures. They turff them to the specialists that do them all the time on a regular basis, b/c of their ratios looks a lot better.
I think you need to take a look at what is happening in rural medicine. Full scope FM is a reality with these docs managing inpts, seeing clinic pts, staffing the ED, delivering babies doing scopes etc... Not hospitalists. And the insitution covers the malpractice.
Here some of what the AAFP has to say about the ACA:
http://www.aafp.org/online/en/home/...ment-medicine/20120628supremecourtruling.html
http://www.aafp.org/online/en/home/media/releases/2012/scotus-aca.html
AAFP Statement: AAFP Welcomes Supreme Court Ruling on ACA
Statement attributable to:
Glen Stream, MD, MBI
President
American Academy of Family Physicians
"The American Academy of Family Physicians is eager to move forward with needed health system reforms now that the Supreme Court has ruled. As a result, more Americans will have access to meaningful insurance coverage and to the primary care physicians who are key to high quality, affordable health services.
"Broad, individual responsibility for health care is the foundation for successful implementation of the Affordable Care Act's patient protections. Economic realities dictate that ensuring affordable coverage for all Americans depends on participation of all Americans. The 2001 Institute of Medicine Report, "Coverage Matters — Insurance and Health Care," confirms that — regardless of their insurance status — virtually all Americans use health care services. Without broad participation in a health care coverage system, health care for all cannot be obtained, let alone sustained.
"The Affordable Care Act reduces numerous financial barriers to care, by requiring coverage despite pre-existing conditions, eliminating annual and lifetime limits on benefits, and eliminating cost sharing for preventive services. It recognizes the value of primary care by bringing Medicaid payment for primary care services to Medicare levels.
"Equally important, however, are the law's provisions that will build the primary care workforce to meet patients' needs. The Supreme Court decision maintains already-launched initiatives that support wider implementation of the patient-centered medical home and that value primary medical care through payment incentives for primary care physicians. Programs such as the Center for Medicare & Medicaid Innovation's Comprehensive Primary Care Initiative and Medicare's Primary Care Incentive Payment can continue to foster a financial environment that builds the primary care physician workforce and helps ensure all Americans have access to a patient-centered medical home.
"The decision allows investment in primary care education and training with improved support for the Health Professions Grants for Family Medicine, funding for teaching health centers, establishment of the Health Care Workforce Commission, and maintenance of scholarships and loan repayment programs in the National Health Service Corps.
"The Affordable Care Act provides a foundation for reforming our health care system, but much work still lies ahead including a permanent replacement for the Sustainable Growth Rate formula and meaningful medical liability reform.
"By upholding the Affordable Care Act, the Supreme Court has ensured that Americans have access to affordable, sustainable health care coverage and that they receive high quality, coordinated and efficient care based on primary care. It is a future that family physicians happily anticipate."
Here some of what the AAFP has to say about the ACA:
http://www.aafp.org/online/en/home/...ment-medicine/20120628supremecourtruling.html
http://www.aafp.org/online/en/home/media/releases/2012/scotus-aca.html
AAFP Statement: AAFP Welcomes Supreme Court Ruling on ACA
Statement attributable to:
Glen Stream, MD, MBI
President
American Academy of Family Physicians
"The American Academy of Family Physicians is eager to move forward with needed health system reforms now that the Supreme Court has ruled. As a result, more Americans will have access to meaningful insurance coverage and to the primary care physicians who are key to high quality, affordable health services.
"Broad, individual responsibility for health care is the foundation for successful implementation of the Affordable Care Act's patient protections. Economic realities dictate that ensuring affordable coverage for all Americans depends on participation of all Americans. The 2001 Institute of Medicine Report, "Coverage Matters — Insurance and Health Care," confirms that — regardless of their insurance status — virtually all Americans use health care services. Without broad participation in a health care coverage system, health care for all cannot be obtained, let alone sustained.
"The Affordable Care Act reduces numerous financial barriers to care, by requiring coverage despite pre-existing conditions, eliminating annual and lifetime limits on benefits, and eliminating cost sharing for preventive services. It recognizes the value of primary care by bringing Medicaid payment for primary care services to Medicare levels.
"Equally important, however, are the law's provisions that will build the primary care workforce to meet patients' needs. The Supreme Court decision maintains already-launched initiatives that support wider implementation of the patient-centered medical home and that value primary medical care through payment incentives for primary care physicians. Programs such as the Center for Medicare & Medicaid Innovation's Comprehensive Primary Care Initiative and Medicare's Primary Care Incentive Payment can continue to foster a financial environment that builds the primary care physician workforce and helps ensure all Americans have access to a patient-centered medical home.
"The decision allows investment in primary care education and training with improved support for the Health Professions Grants for Family Medicine, funding for teaching health centers, establishment of the Health Care Workforce Commission, and maintenance of scholarships and loan repayment programs in the National Health Service Corps.
"The Affordable Care Act provides a foundation for reforming our health care system, but much work still lies ahead including a permanent replacement for the Sustainable Growth Rate formula and meaningful medical liability reform.
"By upholding the Affordable Care Act, the Supreme Court has ensured that Americans have access to affordable, sustainable health care coverage and that they receive high quality, coordinated and efficient care based on primary care. It is a future that family physicians happily anticipate."
Please try to pardon me, b/c you are further along in this process than I am, but truthfully, I think you are being completely na'ive about how the whole thing will in all likelihood pan out.
In the end, it will be more patients for less. The little bump they will give will not be a financial benefit in the longrun. Time will indeed be the most telling, but so is common sense. You can only pour so much into the pail until it runs over--and then you scramble trying to scoop up whatever drops you can thereafter.
The plan is not sustainable, and mostly everyone will take a big hit, including physicians. That's why a lot of them are going to work their butts off as much as they can now in the hope that they will retire in five years. Many of them have been conferring with their financial advisors now to help move this along as quickly as possible.
You might think that will be a good thing for docs in the future, but it really won't be. More than anything, it is and will be quite telling. And for every doc that retires, they will try to shove in 2 or 3 midlevel providers wherever possible. If it's a tough fit, they will push and shove until it fits.
Bottom line is that you just can't get something from nothing. You can only take money and play shell games with the monies, but it the end there will be a lot more losers than winners. It's only going to stretch so far.
The outcome of this election is not good for current or aspiring physicians. It was not good for the stock market today either.
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I am with kdur and think the new boom era for the generalist is coming. The NP thing has been beat to death but I'll mention it again: a higher percentage of midlevels actually specialize at this point. I don't know where this "flood" of NPs is coming from, is there some source stating there's going to be 23423 new NP schools opening up or something?
Reimbursements are going to change for the better for generalists, increased pay for hitting core values like A1Cs (which are being done anyway), more reimbursement for complex patients (a payment based on number of meds or diseases a patient has), and reimbursement for non-direct patient care, such as a phone call. I'm also going to practice rural medicine and have to echo the wide scope of practice that FPs can have. I worked with a rural FP who is covered by the hospital. The clinic that's set up is part of the hospital so all the overhead is covered by the system, not the physician. Furthermore, the physician takes 100% (yes, 100%) of what he bills and isn't sharing with the hospital or under any flat-salary. Additionally, rural visits can actually be billed for more through the hospital system. I also don't know where all this risk, liability, insurance jabber is coming from. Really, how risky is doing a colonoscopy and other procedures? Have you actually seen the percentage of perforations that actually occur? It's abysmally small and even if something did happen it's not like a golden ticket to having your license taken away or being sued into the ground; that's overly dramatic.
I reiterate, this discussion has been beat to death. Maybe you'll end up being correct jllin, whoopie! It doesn't really change the fact that I enjoy FP more and don't base my career decision on the size of my wallet (even if a fat wallet is nicer and I won't complain about it either). I could not be paid enough to do something like rads or anesthesia for 3-4 decades of my life, ugh.
I'm just gonna go ahead and guess jllin and others won't really care about any arguments made for the FP side of things and this discussion will turn out just like the other ones.
Reimbursements are going to change for the better for generalists, increased pay for hitting core values like A1Cs (which are being done anyway), more reimbursement for complex patients (a payment based on number of meds or diseases a patient has), and reimbursement for non-direct patient care, such as a phone call. I'm also going to practice rural medicine and have to echo the wide scope of practice that FPs can have. I worked with a rural FP who is covered by the hospital. The clinic that's set up is part of the hospital so all the overhead is covered by the system, not the physician. Furthermore, the physician takes 100% (yes, 100%) of what he bills and isn't sharing with the hospital or under any flat-salary. Additionally, rural visits can actually be billed for more through the hospital system. I also don't know where all this risk, liability, insurance jabber is coming from. Really, how risky is doing a colonoscopy and other procedures? Have you actually seen the percentage of perforations that actually occur? It's abysmally small and even if something did happen it's not like a golden ticket to having your license taken away or being sued into the ground; that's overly dramatic.
I reiterate, this discussion has been beat to death. Maybe you'll end up being correct jllin, whoopie! It doesn't really change the fact that I enjoy FP more and don't base my career decision on the size of my wallet (even if a fat wallet is nicer and I won't complain about it either). I could not be paid enough to do something like rads or anesthesia for 3-4 decades of my life, ugh.
I'm just gonna go ahead and guess jllin and others won't really care about any arguments made for the FP side of things and this discussion will turn out just like the other ones.
No, listen, you would not believe the drive to push nurses that are in bac and working toward advanced education toward NP--ESPECIALLY FAMILY PRACTICE.
The professors go on and on about how this will be the future, and that physicians in the future will pretty much only be specialists.
You would not believe the drive and dogma on this topic. It's like a goal to get all these nurses to become family practice NPs.
You need to read what a lot of nurse organizations and nurse education organizations are saying and doing in this regard. I have been a professional nurse for a long time. I know exactly what the agenda is. It's not about some wild-eyed hyperbole. It's serious business. And the schools are all too happy to embrace it b/c it brings in a lot of money, and essentially that IS what higher education is about. It's business.
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So what do you suppose is going to happen to all the FPs and primary care pediatricians/internists? And all their organizations and societies? I actually have no idea where you're going with this. NPs are going to take over primary care for the entire country?
I have been a nurse for 15 years prior to med school and I think you are slightly over reacting to this.
First no matter what the "professors" say physicians are not going to become specialists only. The pendulum is swinging back toward generalists (slowly). Also nursing education as you said is a business and part of this push to make more NPs is profit driven (on the school's part).
Secondly, this is good news. Why? Because as you have pointed out there will be an increases of patients and we will need our mid-level providers to help with this influx. You mentioned physician burnout, well this should help minimize this.
In the end, if NP/PA can help provide care for people who need help, great. FM docs will not be pushed out. As long as I can provide for my family I am fine with it. I never needed (or expected) to become rich in the process.
I am fine with the ACA and the growth of mid-levels. Things were not working before. And while the ACA is not perfect it is a step in the right direction. And that is where it seems that we have our major difference.
Hey all, long time lurker on a newish account -- quick question: I really thought that obamacare was supposed to be a huge boon for FM. I've heard some politicians talk of even unionizing doctors... and if it ever comes to that I want to know that I didn't spend 5+ years in a super sub-specialty learning one organ/system. We have Primary care tracks at my school that pays for your tuition, and with obama's re-election, FM looks a lot more appealing.....
Also, another big question I was hoping someone could shed some light on: I went into medicine to be my own boss (in addition to helping people obviously). Is it *really* a thing of the past to own your own clinic?
Thanks--
Also, another big question I was hoping someone could shed some light on: I went into medicine to be my own boss (in addition to helping people obviously). Is it *really* a thing of the past to own your own clinic?
Thanks--
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Nothing is impossible, in a saturated area it will be a lot more challenging to own your own practice. I know a lot of doctors who have made their own niche in the field and do very well not being a slave in the system. You'll likely start out working with a group or employee of a hospital until you get on your feet.
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No, although right now, the trend is to merge practices because the changing nature of health care (EMR, etc) are forcing practices on the margin to be acquired by larger groups or hospital systems, because they have a larger cash position. Older docs remember this recently as early as 90's with the take-off of HMO's with multiple acquisitions, some of which don't pan out. There will always be room for private practice. The question is are you positioned well to weather the storms.
Affordable Care Act (ACA) sets up Accountable Care Organizations (ACO), which may be 1 institution or 1 health care system but it doesn't need to be. You can be a part of an ACO while maintaining your own private practice. There's a provision in ACA that allows doctors who participate in ACO's to collectively bargain their reimbursement rates when they go to the market. ACA "allows unionization" by protecting physicians from anti-trust and FTC lawsuits. In return for this safety harbor, physicians who are a part of the ACO agree to risk-sharing arrangements ($$) and undergo quality improvement projects and make those benchmark data available for everyone to scrutinize.
So for example, as an FM doc, I'm a part of an ACO. That ACO includes my group, my hospital system, and a bunch of other doctors from other groups/practices. We (the ACO) approach the insurance market as a group and say that we will take care of their patients for a certain price. They either get all of us or none of us. We agree to accept large payment from the insurance company and we will figure out how to divide it up amongst ourselves. The less we spend, the more we all make. The incentive is for us to control our costs by ordering less tests inappropriately, use the hospital less, etc. Research supports that FM are in the best position to take care of patients because of our lower rates of utilization and therefore it behooves ACO's to funnel patients to FM docs and have them manage their care and preventing problems, in hopes of saving on the back end. The insurance company doesn't care how you manage them. They leave it up to the doctors to figure out how to do it effectively/efficiently.
The responsibility therefore shifts to the doctors and the hospital health system to figure out a way to work together. The best way is to track your own numbers and publish them, and if you end up being a high cost, low quality doctor, the other doctors in the ACO can kick you out. So, to be a part of the ACO, you promise to publish your A1c's, mammogram rates, blood pressure controls, colonoscopy rates, hospital readmission and that allows people to compare you versus other primary care doctors. Specialists have their own metrics that they follow.
As part of the ACO, you need to figure out how to work together with other doctors and facilities. For example, if a patient sees you (as an FP), gets admitted to a hospital, gets discharged, needs a colonoscopy, but needs a stress test first, it's in the best interest of all parties to make sure all of these things happen and that nothing is duplicated. This is where the Information Exchange and Care Coordinators come in. Your practice (or the ACO) may provide a clinical person to coordinate these things. In small practices, it's the doctor, but in large practices, you can hire an LVN or RN with case management experience to do all this. Or, the ACO can hire someone and send them to your office to help coordinate this care. The Information Exchange allows for parts of your chart to automatically get uploaded to a central health system database, so that you can aggregate the data from everyone's office and any facility within the ACO that the patient visits. Because you have access to better information, you make better decisions and don't duplicate information. And, because an ACO is a physician-led organization, if someone doesn't play well together with others, the ACO can kick them out.
ACO's are a way for doctors to get together ("unionize") and self-govern. It's intimidating because you put your stats out there and make yourself vulnerable to lose money. But, if you do everything you can for the benefit of the patients, your stats will follow. And, you'll be fine.
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Thanks for taking the time on the great explanation.
Does this include Medicare and Medicaid reimbursement?
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lowbudget- where do you get your info on ACOs? Looking for a good resource.
Thanks for the info-- appreciate you taking the time to reply. Glad to hear there's hope for the private practice gig. I realize a lot of people could be happy with just a paycheck from somebody else, but I wouldn't mind having my own rural practice someday.
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Accountable Care Organization
http://en.wikipedia.org/wiki/Accountable_care_organization
Accountable Care Organizations and Family Medicine
http://www.aafp.org/online/en/home/practicemgt/specialtopics/designs/practiceaffiliationoptions.html
What Family Physicians Need to Know About ACOs
http://www.aafp.org/fpm/2011/0900/p17.html
AAFP: Medicare Shared Savings Program: Accountable Care Organizations final rule
http://www.coloradoafp.org/pdf/AAFP-Final-Medicare-ACO-Summary.pdf
http://en.wikipedia.org/wiki/Accountable_care_organization
Accountable Care Organizations and Family Medicine
http://www.aafp.org/online/en/home/practicemgt/specialtopics/designs/practiceaffiliationoptions.html
What Family Physicians Need to Know About ACOs
http://www.aafp.org/fpm/2011/0900/p17.html
AAFP: Medicare Shared Savings Program: Accountable Care Organizations final rule
http://www.coloradoafp.org/pdf/AAFP-Final-Medicare-ACO-Summary.pdf
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Traditional Medicare, yes. I don't know about Medicaid.
The ACO can also approach private insurance, like Cigna, Aetna, BCBS, United, and negotiate a contract.
ACO's differ from HMO's in that ACO's are put together by doctors (therefore doctors are in charge) where as HMO's are put together by insurance companies (therefore the insurance company is in charge). That being said, an HMO can participate in an ACO; and therefore some Medicare HMO's (through Medicare Advantage plans can participate or form their own ACO's).
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