Are specialists responsible for the collapsing US medical system?

[sophiejane]

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I heard a story on NPR this morning that made me wonder:

http://www.npr.org/templates/story/story.php?storyId=95720324

Is the exaltation of procedural and specialist medicine responsible for the overwhelming cost of the US healthcare system?

In the study mentioned in the NPR piece, they found only about 40% of patients receiving angioplasty had ever had a stress test first, even though in many cases, angioplasty is LESS effective than optimal medical management.

Our system is set up to financially reward proceduralists and specialists, and those are the LEAST cost effective ways to solve medical problems.

Thoughts?

 

[MOHS_01]

I heard a story on NPR this morning that made me wonder:

http://www.npr.org/templates/story/story.php?storyId=95720324

Is the exaltation of procedural and specialist medicine responsible for the overwhelming cost of the US healthcare system?

In the study mentioned in the NPR piece, they found only about 40% of patients receiving angioplasty had ever had a stress test first, even though in many cases, angioplasty is LESS effective than optimal medical management.

Our system is set up to financially reward proceduralists and specialists, and those are the LEAST cost effective ways to solve medical problems.

Thoughts?

Sophie,

This is a very politically charged topic in medical circles (particularly in a FP forum), and as such is quite difficult to discuss honestly without getting emotions tainting opinions, but I'll give it a try.

Speaking on the payment issue first (since that is where everyone ultimately focuses) -- a historical perspective is necessary in order to form an understanding of how we got to where we are today. Prior to 1992 physicians were largely reimbursed based upon a "usual and customary" fee structure. There were (rightfully so) concerns that this system unduly rewarded procedures at the expense of cognitive services, thus the development and adoption of the RBRVU system that we use today. Perhaps this change did not go far enough, but it did go a long way in addressing the imbalance (contrary to what many believe). This system also bases the RVU associated with any service in large part on the costs associated with providing that service. While it is true that the current system is not without its flaws, no one has thus far been unable to suggest a better system that takes the multitudes of variables into account.


There is no doubt that numerous procedures are performed every day that have no proven utility. I believe that there needs to be good, evidence based guidelines for procedural utilization based upon what works -- the problem is that in many cases we don't have that kind of information available. To paint procedures as evil and medical management as good, however, is simplistic (and frankly inaccurate in many circumstances). A good timely intervention is often the best and most cost-effective treatment alternative.

I would still like to see the data that shows that PCP's can do my job better (or cheaper) than I can. I simply don't believe that it exists, in large part because it is not true. There is a reason that my referral only practice is booked out for months......

 

[sophiejane]

I would still like to see the data that shows that PCP's can do my job better (or cheaper) than I can. I simply don't believe that it exists, in large part because it is not true. There is a reason that my referral only practice is booked out for months......

I don't believe I ever said PCPs can do YOUR job better than you can.

I'm sure your referral-only practice is booked out for months because you are a good doctor with a good reputation and happy patients. That is beside the point of this discussion. We are not talking about how PCPs should do everything that specialists do, which is also a very simplistic view of this discussion.

Let's redirect: we are talking about whether the fascination with the newest, highest tech procedures, and the impression that the lay public has that newer and more bells and whisltles=more effective treatment, is still appropriate given the fact that our healthcare system is the most expensive in the world, while providing, dollar for dollar, the least amount of care to Americans.

 

[MOHS_01]

I don't believe I ever said PCPs can do YOUR job better than you can.

I'm sure your referral-only practice is booked out for months because you are a good doctor with a good reputation and happy patients. That is beside the point of this discussion. We are not talking about how PCPs should do everything that specialists do, which is also a very simplistic view of this discussion.

Let's redirect: we are talking about whether the fascination with the newest, highest tech procedures, and the impression that the lay public has that newer and more bells and whisltles=more effective treatment, is still appropriate given the fact that our healthcare system is the most expensive in the world, while providing, dollar for dollar, the least amount of care to Americans.

I absolutely, 100% agree that this is a HUGE problem... and imaging is the very first thing that comes to mind on this matter. So the argument is not specialist vs generalist, per se, it is more utilization frequencies of high cost technologies and treatments relative to other specialties? If so, that is a somewhat problematic argument to make as specialists will naturally be skewed toward ordering their respective studies... which does not go very far in addressing the core issues of costs.

For instance, let's look at what they did with cataracts and compare that to, say, MRI's. Utilization frequencies went up, the cost associated with hard asset procurement went down as a result of volume, eye guys have their legs cut out from under them. The same thing should be done for MRI scanners as utilization rates go up. In addition, it should be pointed out that there exists a perverse incentive for increased utilization in the current system; this systematic problem needs to be addressed through sound practice guidelines if we are ever to hope to reign in costs.

 

[Spleen]

Specialists are merely a symptom. Our system collapse is directly the fault of CMS and the ripple affect upon payment. This weakened the system so the opportunistic insurance company boils could take hold. And some where along the way we picked up and STD called Lawyer Toofrickinmanyofthem.

Solution: Stop rallying for medicare. Just let it die. Unlink insurance from empoloyment so we once again pay for it ourselves. When things are free, or you don't know what it costs you spend more. You don't value it. Do you eat more when you go out to eat on your own dime, or when a drug rep pays for it? Allow balance billing. Only use insurance for catastrophic reasons. Primary docs are to be paid out of pocket - you do this, and with less office staff we can charge less and care less about insurance opinions on management. Tort reform and close 50 of the 200 law schools. Get rid of EMTALA, give common sense back to the Emergency docs.

 

[yumita]

Wow, so poor people (read: middle class and poor people) will be even less able to afford health care. Is that really what you want? People should utilize the health care system. It's called prevention, screening and chronic illness management. If you make health care inaccesible then you make us all sicker. Imagine a pregnant woman who, for lack of prenatal care ends up with a sick or developmentally delayed child. This child becomes a member of our society and one who is less productive. I hate to put it in such cold capitalistic terms, but obviously that is the way you are thinking about health care.

 

[Spleen]

Yes, you are absolutely right. There is a risk that a more capitilistic medical system would leave some people out to dry and the economy and society would suffer from something preventable in a potential worker.

Conversely we could socialize every thing and give care to every one. This further disincentivizes people from working harder and the economy and society again will suffer. The question is which does the least damage to the economy and the greater good of society? You know my vote. How many people have you seen who are just plain lazy living off the system? They get so obese their bodies simply fail them, and we cover them darn near cradle to grave for all their pain meds, assissted living, numerous specialist consults for knee and back pain, stasis ulcers, DM issues, etc... How laid back and relaxed are the work days in europe? How much productivity do they have compared to us? If our end measure is economic benefit, then I am in the camp that socialized medicine would be more hurtful in the long wrong to our economy (not considering the direct cost of funding it). With less reasons for one to work hard to obtain the things necessary for a really good life, why bust your toosh? I for one won't. People are inherently lazy, especially in our country - just think of our prevailing me attitude. Our country will suffer in the long run.

Preventive care is cheap. It is expensive right now because of the things previously mentioned. The bureaucratic insurance machine and hours of papers needing shuffling, stamping, reviewing, filing, mailing, shredding, faxing, losing, etc. are all done by people (I bet these salaries all add up to more than physician salaries...). Expensive resulting from defensive medicine due to the lawyers. If you get rid of these things, costs will go down!

 

[MidwestFM]

Let's redirect: we are talking about whether the fascination with the newest, highest tech procedures, and the impression that the lay public has that newer and more bells and whisltles=more effective treatment, is still appropriate given the fact that our healthcare system is the most expensive in the world, while providing, dollar for dollar, the least amount of care to Americans.

I agree. And I think the following article directly addresses your original question: When measured county by county in the US, places with more primary care docs per capita have better outcomes than places heavy in specialists.
http://www.ncbi.nlm.nih.gov/pubmed/15769797

 

[Frijolero]

(snip)

I would still like to see the data that shows that PCP's can do my job better (or cheaper) than I can. I simply don't believe that it exists, in large part because it is not true. There is a reason that my referral only practice is booked out for months......

Obviously an FP can't do your entire job better (or cheaper) than you but a good one can certainly do at least parts of it cheaper. Consider the almost daily basis upon which I see a patient for a completely unrelated problem and end up freezing/removing the random AK/SK/etc. they mention at the end of the visit. Similarly, while I'm sure your skills at excisional biopsy far exceed mine, doing it in my office means no referral, no driving somewhere else, and no new-patient paperwork. Clearly I'm not capable of doing Mohs, but for the majority of minor derm stuff, I can do it cheaper because it's usually in combination with something else.

 

[sophiejane]

Fractured healthcare is expensive and inefficient healthcare.

PCPs should do more for our patients and save them the often unnecessary expense (and risks) of procedure-laden specialist-heavy, fractured medical care.

We need to be handling more and referring less. The more I do this, the more I realize how much of this I can do. Obviously, when you need a surgeon or ID or neuro, you need them. But I think, as a whole, we refer way too much.

Are specialists seeing only truly appropriate referrals? I don't think so. That's why they hire midlevels, which is terribly ironic. You go to the specialist and all you see is a nurse. You'd be better off seeing an actual doctor at your PCP's office. I think cardiologists (or their midlevels) manage a lot of very routine CHF and hypertension. I think dermatologists (or their midlevels) see a lot of mild-moderate acne and eczema and routinely do biopsies that any FP that half-paid attention in residency could handle.

{I'm ready for the burning arrows, I know they are coming.}

We have the most expensive medical system in the world (except perhaps for Japan, but theirs is heavily subsidized)...and I maintain that it is one of the least efficient. For the amount of money we spend on healthcare each year, there is NO reason why every American can't have basic healthcare. Or maybe there is. Maybe it's because so many people think you have to go to a gastroenterologist for your stomach ache or a neurologist for your headaches. And they end up getting MRIs and scopes and procedures they wouldn't have needed if someone would have taken the time to do a decent H&P and a thorough physicial.

It is stunning the number of clues many specialists miss on basic histories because they are so narrowly focused. The lady with very obviously non-neurologic syncope gets an MRI and an EEG and a neuro consult when all she really needs is orthostatic BPs and someone to really sit down and listen to her story.

And we all know the old joke (that's not really a joke) that everyone who walks through the doors of the ED gets a head CT. They aren't ordering them because they are all truly indicated or even because the doctors think they will get sued. They order them because it's faster and easier than doing a complete, focused history and physical. When you are getting paid per patient, it's no wonder you'd rather run everyone through a machine than actually sit down and try to figure out what's wrong with them.

 

[EdibleEgg]

A few years ago I got a call from a friend in law school. She was cramming for a final in the school library when she stood up from her desk and bumped her elbow. She became light headed and had a brief syncopal episode. She was out for a few seconds. EMS was called by the library staff; she had normal vitals and screening neuro exam. She declined a trip to the ER and called me later that night. I told her it sounded like vasovagal syncope, but she should see her PCP if she was concerned.

Her husband, who is a business consultant in a hospital decided he could do a little better, and pulled some strings to get her in to see the chair of the department of neurology at the medical school associated with the hospital. Three days later, after a sleep deprived EEG, CT Head, MRI Head, Cardiology consult, labs, etc, etc, she was discharged with a diagnosis of .......... vasovagal syncope.

I'm not at all mudslinging or playing Monday morning quarterback. I'm sure that neurologist is a very smart guy. There are plenty of people around that can point out my mistakes, or point out a needless a MRI ordered by an FP. However, if you have a hammer then the world is a nail. Or if you have a new cardiac CT in your office, the world is a cholesterol laden LAD. Our top heavy system is ONE of the big problems with US healthcare.

 

[MOHS_01]

No burning arrows here -- like I stated at the beginning, this is an issue where I expect disagreement. I did not develop my views because I chose to specialize -- I chose to specialized because of my views.

So many things here.... first, to address the frozen AK / SK / etc comment: medical costs, as we most commonly discuss them, are measured from the fees incurred vantage point -- so you are absolutely correct that taking care of something appropriately in your office, at the time of some other service that is already being rendered, is cost effective as a new E&M is saved. What many on SDN incorrectly believe, however, is that a specialist is paid more for rendering a service than a PCP is (which absolutely is not true).

Another problem that bears discussing is the enormity of the task of knowing when and what to refer, which I believe is the single hardest job that any doc (particularly PCP's) has. I have some referring providers who refer any and every little thing... and then some who never refer anything (that is until they have f***ed around with things long enough to create some form of problem, usually medicolegal, and then I get thrown into the middle of a mine field). I know when I see their name at the top of the chart that I need to hold on with both hands when I walk through the door... case in point, I excised two melanomas today; one of which has been observed for two years, the other had been frozen twice... that was two today. There are enough subtleties to much of this skin stuff that I cannot throw stones, and I explain this to patients every single day... great docs will miss things, and I inform them that I am caught off guard and surprised several times a year, and I am supposed to be "a specialist"...

One final thing regarding healthcare reimbursement structure -- FFS is arguably the fairest form of reimbursement despite its shortcomings. We simply cannot afford to pay someone to the tune of $150k per year to sit down with Johnny and discuss his life story for an hour... just to figure out what his diet is and how he got to be as big as a house (when we all know from the get go that it is a thyroid condition 🙄 Capitation does not work as it perversely incentivizes the rationing of care. Straight salary is only acceptable if one is willing to give up professional autonomy and accept orders / quotas / instructions from their employer. We simply need to be provided for the work that we perform; someone who does a good job for 30 people a day should be paid better than someone who does a similar job for 15 people a day; this should not be proportional, either, as that is not the way that economics in our (pre-Obama, at least) society works. That said, incentives should be built into the system that rewards good, cost effective behavior and penalizes unnecessary care.

 

[MOHS_01]

A few years ago I got a call from a friend in law school. She was cramming for a final in the school library when she stood up from her desk and bumped her elbow. She became light headed and had a brief syncopal episode. She was out for a few seconds. EMS was called by the library staff; she had normal vitals and screening neuro exam. She declined a trip to the ER and called me later that night. I told her it sounded like vasovagal syncope, but she should see her PCP if she was concerned.

Her husband, who is a business consultant in a hospital decided he could do a little better, and pulled some strings to get her in to see the chair of the department of neurology at the medical school associated with the hospital. Three days later, after a sleep deprived EEG, CT Head, MRI Head, Cardiology consult, labs, etc, etc, she was discharged with a diagnosis of .......... vasovagal syncope.

I'm not at all mudslinging or playing Monday morning quarterback. I'm sure that neurologist is a very smart guy. There are plenty of people around that can point out my mistakes, or point out a needless a MRI ordered by an FP. However, if you have a hammer then the world is a nail. Or if you have a new cardiac CT in your office, the world is a cholesterol laden LAD. Our top heavy system is ONE of the big problems with US healthcare.

VERY, very true... and this is where appropriate regulation and oversight come in.

 

[lowbudget]

Sophie,
I listened to the NPR piece when you posted it. I haven't had a chance to pull the article they're referring to, but was wondering if you have?

We all know that exercise stress pays less than caths, but we also know that the diagnostic utility of exercise stress depends on your pretest probability. I'm curious as to how they came to the conclusion they arrived in...

To say that PCP = affordable, appropriate therefore good; and Specialists = expensive, unnecessary therefore bad, is to paint a complex world broadly with, perhaps, oversimplifying strokes in hopes that we can understand and feel good about it.

I'm wondering if the NPR piece is oversimplifying the article for public consumption...

 

[EdibleEgg]

incentives should be built into the system that rewards good, cost effective behavior and penalizes unnecessary care.

I absolutely agree, but I'm not sure how to do this fairly under the current system. One of the reasons for such a high rate of referrals is the current fee structure.

 

[andwhat]

One final thing regarding healthcare reimbursement structure -- FFS is arguably the fairest form of reimbursement despite its shortcomings. We simply cannot afford to pay someone to the tune of $150k per year to sit down with Johnny and discuss his life story for an hour... just to figure out what his diet is and how he got to be as big as a house (when we all know from the get go that it is a thyroid condition 🙄 Capitation does not work as it perversely incentivizes the rationing of care. Straight salary is only acceptable if one is willing to give up professional autonomy and accept orders / quotas / instructions from their employer. We simply need to be provided for the work that we perform; someone who does a good job for 30 people a day should be paid better than someone who does a similar job for 15 people a day; this should not be proportional, either, as that is not the way that economics in our (pre-Obama, at least) society works. That said, incentives should be built into the system that rewards good, cost effective behavior and penalizes unnecessary care.[/QUOTE]


Primary Care docs should get compensated much better for procedural work.

 

[deleted87716]

I did not develop my views because I chose to specialize -- I chose to specialized because of my views.

Heh...me, too. 😉

taking care of something appropriately in your office, at the time of some other service that is already being rendered, is cost effective as a new E&M is saved.

Not to mention that patients appreciate it.

What many on SDN incorrectly believe, however, is that a specialist is paid more for rendering a service than a PCP is (which absolutely is not true).

Again, this is insurance dependent. I have friends in derm who get paid nearly double what I do for the same procedures. It all depends on how they've negotiated their fee schedule. Only Medicare pays uniformly.

FFS is arguably the fairest form of reimbursement despite its shortcomings.

I agree. God save capitalism.

 

[sophiejane]

To say that PCP = affordable, appropriate therefore good; and Specialists = expensive, unnecessary therefore bad, is to paint a complex world broadly with, perhaps, oversimplifying strokes in hopes that we can understand and feel good about it.

I'm wondering if the NPR piece is oversimplifying the article for public consumption...

Not saying that. I never said specialists were unnecessary, that would indeed be ridiculous, and neither I nor the NPR piece ever implied that.

I said I think we ask specialists to do a lot of things that are not the best use of their training and expertise, things easily handled by a well trained PCP.

I said I think over-relying on specialists to handle everything beyond the most basic medical problems causes people to have more procedures than they likely need.

 

[sophiejane]

someone who does a good job for 30 people a day should be paid better than someone who does a similar job for 15 people a day

This type of system rewards speed, and that can be very dangerous in primary care.

The sarcasm in the comment about sitting down with fat Johnny was not lost on me. It's my JOB to figure out the story and get it right the FIRST time. I have seen what happens when 5 specialists re-dictate the same hurried and incomplete H&P done by a tired resident at 3 am who forgot some very important details. I'm not saying it will take an hour, but it will take longer than it would for you to freeze off his warts, that's for sure.

Because you only have to focus on skin, you CAN see 40 people a day. But because I have to figure out whether this is bipolar or MDD, whether thyroid is involved, set up their colonscopies and mammograms AND help them find out which WalMart/HEB (a Texas thing!)/Target $4 list they can get their meds on because they don't have insurance....why should I be penalized for that if it means I can only see 25 in a day?

Help me understand how it makes sense to penalize the folks who prevent the expensive problems in the first place...

 

[EdibleEgg]

MOHS...

Are you really implying that FP's spend the day discussing life stories? The last patient I spent an hour with was septic on the vent and two pressors. That's even a step below implying that dermatologists spend the day prescribing lotrisone and freezing warts. 🙂

Seriously, "specialists" aren't the problem. I'm happy to have some backup. There's a lot I don't know. We have a specialist heavy system that disproportionately rewards specialists, encourages needless intervention, and forces defensive medicine. That's the problem.

 

[MOHS_01]

MOHS...

Are you really implying that FP's spend the day discussing life stories? The last patient I spent an hour with was septic on the vent and two pressors. That's even a step below implying that dermatologists spend the day prescribing lotrisone and freezing warts. 🙂

Seriously, "specialists" aren't the problem. I'm happy to have some backup. There's a lot I don't know. We have a specialist heavy system that disproportionately rewards specialists, encourages needless intervention, and forces defensive medicine. That's the problem.

No, not implying that at all -- just pointing out that the lower volume of services rendered in your typical primary care practice when compared to my field is the single greatest contributing factor to revenue disparities. The increased intensity of these services cannot offset the volume, unfortunately.

If we really want to remove all false pretenses, I honestly believe the healthcare delivery model is set to change -- where docs will predominantly be responsible for higher level cognitive services, procedures, etc, while mid level providers will be responsible for the vast majority of the day to day operations. We are all going to be forced into industrialization, incorporating efficiencies that we are not comfortable with today. The historical physician / patient relationship will be eroded away due to reimbursement issues...

I am quite sympathetic to the PCP cause, believe it or not, and have devoted many (many) hours to developing a system (along with the help of some very smart folks) where these disparities can be addressed appropriately, all the while ensuring that quality care is protected. I believe that we are getting close....

 

[MOHS_01]

yes, I agree with you. We should continue to overpay people to 'freeze warts' and 'pop pimples' off. You tell me what is 'unnecessary' care.
Undermining the value of counseling? Why is it stressed in medical school?? What do YOU want to happen?
Sorry I am going to diverge here, and talk about the issue of counseling -- Every single overweight person should go to Bariatric surgery? That is not an answer -- look at Roseanne Barr for instance, she is more fat now, then she was before her surgery. Bariatric surgery is a TEMPORARY fix, that lasts less than one year usually, sometimes even months.
I know, how about we TAKE OUT OF SOCIETY McDonald's, KFC, Pizza Hut, and Burger King?
Not going to happen is it? So why gripe about it? What is your fix on the situation.
Counseling is a HUGE part of medicine on a daily basis -- educating individuals about health conscientious behavior.
It is negligible whether or not they have a 'thyroid' condition. Counseling is counseling. Physicians should get paid well for it.
Reality is, that every single specialty performs skin procedures, including Neurology. (welll maybe not Psych and PM & R)
As a resident, I routinely performed at least 10 skin procedures a week in clinic -- sometimes 5 in a day!! -- and RARELY referred out to Derm.
I can get a patient into derm within the SAME WEEK - thus I am not sure where you live.
I routinely sent my 'psych' patients to Derm, that were solely fixated that they had a skin condition. I did not want them to continue to pester my residents (during residency).
If I were in private practice, I would NEVER refer to derm -- maybe send them to Mayo clinic to get Mohs surgery.
Even eyelid lesions, I refer to Opthalmology, NOT derm.
You have your specialty base of patients from referrals. You should appreciate that.
What would happen, if FM docs stepped out of the system? The system would collapse and LITERALLY.
What would happen if Derm docs stepped out of the system? More people would go to FM and IM docs to have their warts frozen, and pimples popped. Sorry for depicting reality. Thats what it is.
I get ads all of the time, from clinics begging internists and FM docs to learn how to do Derm procedures, and help their practice. For the money, I would do it. Its just too boring?!
I do not feel as if I am really helping society doing skin procedures all day.
I would love to hear your perspective to the contrary.

andwhat,

Where to begin... OK, the most dangerous physician is one who does not know his limits, and to say that one "never refers to" any given specialty speaks to a lack of understanding (i.e. ignorance) that cannot be appropriately addressed in a forum such as this and is a matter best taken up with the state board of licensure.

Patient education is vital; indeed it is arguably the most important service that we provide. HOWEVER, it simply is not practical to pay someone to preach; teaching can take many forms, and if a physician chooses to spend his day speaking verbally in a one on one fashion to patients for the purposes of counseling, they he voluntarily chooses the financial limititations that comes with that decision. Pamphlets, videos, midlevels, MA's, RN's, etc are available -- use them.

You will never, ever hear me say that we should have vice taxes, restrictions on fast food, etc -- personal responsibility is the overiding tenet of my belief system. If a person chooses to become morbidly obese through the abuses of twinkies and french fries, then they deserve the rewards that the condition provides. No amount of telling them that it is bad for them will effect change....

One last thing -- if someone sends their eyelid tumors to optho (and nothing against the eye guys) instead of a trained MOHS guy, then they are even less well informed than given credit for...

 

[MOHS_01]

This type of system rewards speed, and that can be very dangerous in primary care.

The sarcasm in the comment about sitting down with fat Johnny was not lost on me. It's my JOB to figure out the story and get it right the FIRST time. I have seen what happens when 5 specialists re-dictate the same hurried and incomplete H&P done by a tired resident at 3 am who forgot some very important details. I'm not saying it will take an hour, but it will take longer than it would for you to freeze off his warts, that's for sure.

Because you only have to focus on skin, you CAN see 40 people a day. But because I have to figure out whether this is bipolar or MDD, whether thyroid is involved, set up their colonscopies and mammograms AND help them find out which WalMart/HEB (a Texas thing!)/Target $4 list they can get their meds on because they don't have insurance....why should I be penalized for that if it means I can only see 25 in a day?

Help me understand how it makes sense to penalize the folks who prevent the expensive problems in the first place...

Sophie,

Forgive me if this does not flow well -- it has been a long day...

I do not believe that you, or anyone else, should be penalized for providing these services, and I fully acknowledge the fact that minor procedures are inappropriately reimbursed relative to E&M... The real issue here is the inadequate reimbursement of higher level E&M codes from my perpsective, along with the inherent inefficiencies of the medical history taking process. Everyone needs to understand, however, that the service levels provided by dermatology are predominantly low level services, rarely more than a level 2 new or level 3 established (often 1 and 2, respectively)..

I always choose something off of the $4 dollar list if possible... and I hate WalMart, but I hate wasting money even more...

 

[MOHS_01]

Heh...me, too. 😉



Not to mention that patients appreciate it.



Again, this is insurance dependent. I have friends in derm who get paid nearly double what I do for the same procedures. It all depends on how they've negotiated their fee schedule. Only Medicare pays uniformly.



I agree. God save capitalism.

So the derms get 200+% of MC for some of their procedures???? I have got to move to your neck of the woods.... as for the second part, God help us all if the polls are correct... we will find ourselves looking to Australia for capitalistic envy should the U.S.S.A. come to fruition....

 

[deleted87716]

So the derms get 200+% of MC for some of their procedures????

Don't forget that specialists also get to bill the more lucrative consult codes for their initial visits, and patients pay higher co-pays to see them. If most of your visits include a modifier-25'd minor procedure (biopsy, cryo, comedone extraction, etc.), it really adds up.

The bottom line is that most specialists currently receive better rumeneration for their time in the office compared to most primary care doctors, even if you leave out the big-ticket procedures. Their overhead is usually lower, too. Plus, due to their limited scope, they're frequently able to see more patients in the same amount of time. Most of my specialty colleagues see around 40 patients a day to my 25.

Things may be different in your practice, but that's the way it works around here.

 

[Joe Richards]

That's the way it works in most places.

Don't forget that specialists also get to bill the more lucrative consult codes for their initial visits, and patients pay higher co-pays to see them. If most of your visits include a modifier-25'd minor procedure (biopsy, cryo, comedone extraction, etc.), it really adds up.

The bottom line is that most specialists currently receive better rumeneration for their time in the office compared to most primary care doctors, even if you leave out the big-ticket procedures. Their overhead is usually lower, too. Plus, due to their limited scope, they're frequently able to see more patients in the same amount of time. Most of my specialty colleagues see around 40 patients a day to my 25.

Things may be different in your practice, but that's the way it works around here.

 

[andwhat]

Sophie,

Forgive me if this does not flow well -- it has been a long day...

I do not believe that you, or anyone else, should be penalized for providing these services, and I fully acknowledge the fact that minor procedures are inappropriately reimbursed relative to E&M... The real issue here is the inadequate reimbursement of higher level E&M codes from my perpsective, along with the inherent inefficiencies of the medical history taking process. Everyone needs to understand, however, that the service levels provided by dermatology are predominantly low level services, rarely more than a level 2 new or level 3 established (often 1 and 2, respectively)..

I always choose something off of the $4 dollar list if possible... and I hate WalMart, but I hate wasting money even more...

Compensation in Derm is overpriced, but hey thats how medicine goes.
I deal with life and death literally on a daily basis -- family meetings, codes, etc -- and get compensated less than a specialist, this should change.
I do more work, or the same, and get compensated less than a Dermatologist.
That should change.
It is not like I did not refer to Derm when I absolutely had to -- remember I did refer my 'psych' patients to Derm, that were absolutely convinced that they had a skin disorder.
Remember, Derm is part of our certification boards, and it is a rotation in IM also. Derm questions are asked on our certification boards, and on the IM boards as well.
We are required to identify and treat skin lesions.
As a matter of fact, once my colleague referred a patient to Derm, the Dermatologist did not do a skin biopsy. The patient was sent back to the FM office, biopsied, and diagnosed. I do not know what the outcome of the procedure was. If a Derm guy will not do what they are asked to do from the referring physician, honestly what is the point??
I strongly believe in a referral system. I do not believe that Derm is important enough to consistently refer to, unless there is something complicated like Mohs procedure.
Everything in FM is important also? No of course not. Urgent Care for instance, is a 'specialty', where more than 90% of the ailments can be treated by a PA or NP.
I performed the majority of skin procedures on patients myself -- with excellent outcomes -- and my patients were very very satisfied.
I believe that a well trained FM doc should be confident in identifying and treating most Dermatologic conditions.
That being said, I would never ever dream of sending a patient to a Dermatologist, after I 'botched' up a procedure. If it is a straightfoward case, I will happily accept it.
If I could leave margins behind, I will refer it in a heartbeat.

 

[MOHS_01]

To be perfectly honest, I have never understood the rationale behind a consultation being reimbursed higher than a new patient encounter. I also understand that many specialists see a higher volume of patients compared to a primary care person -- my problem is that I know so little about what goes on during a primary care encounter that I cannot comment intelligently on the subject. I do know this -- when I was a student on ambulatory rotations I always felt confined and restrained on my FP and IM rotations. I felt as if the entire process was a little inefficient and it grated on me; now that is probably more a reflection on my turn and burn mannerisms (identify the problem, outline the solution, execute excellently, pat on back, next patient please... only a little tongue in cheek).

My vision of "the primary care office of tomorrow" would have to include multiple mid levels and RN's doing the bulk of the counseling, education, information gathering, etc -- and the MD would be responsible for managing, oversight, quality control and assurance, etc... anyone wishing to maintain the current one-on-one MD time would either have to have one of McCain's "gold plated plans" or pay some form of luxury tax / retainer / concierge fee. You simply do not get paid well enough to continue things as they are, and any changes in the reimbursement structure would likely fall short..

Please keep in mind that remuneration per unit time is largely driven by the costs per unit time in any given specialty. CMS (through the AMA RUC and independent verification from my understanding) actually publicly publishes this information on their website. "Overhead" is overwhelmingly a function of revenue generated, which is often physician dependent as much as it is specialty dependent.

Bottom line is that we agree -- the system is biased toward procedures... our only disagreement, likely, is to what extent and which procedures are the most grossly misvalued. The examples cited above (freezing warts, AK's, some forms of skin biopsies) are well paid for the time that they involve -- but PCP's could, should, and do perform a significant number of these, so I would not draw too much attention to them (even if you are not the one seeing the lion's share of those benefits. Remember that general dermatology is a high cost service to provide -- anyone outside of the field who performs the same procedures benefit from these high costs disproportionately as well).

 

[MOHS_01]

Compensation in Derm is RIDICULOUS AND MUST CHANGE.
I deal with life and death literally on a daily basis -- family meetings, codes, etc -- and get compensated less than someone in a corner office freezing warts and popping pimples? Freakin completely insane.
I do ten times the work of a Derm guy, and make less.
That has to change. It is simply absurdity.
It is not like I did not refer to Derm when I absolutely had to -- remember I did refer my 'psych' patients to Derm, that were absolutely convinced that they had a skin disorder.
Remember, Derm is part of our certification boards, and it is a rotation in IM also. Derm questions are asked on our certification boards, and on the IM boards as well.
We are required to identify and treat skin lesions.
As a matter of fact, once my colleague referred a patient to Derm, the Dermatologist did not do a skin biopsy. The patient was sent back to the FM office, biopsied, and diagnosed. I do not know what the outcome of the procedure was. If a Derm guy will not do what they are asked to do from the referring physician, honestly what is the point??
I strongly believe in a referral system. I do not believe that Derm is important enough to refer to, unless there is something complicated like Mohs procedure.
I did all skin procedures on patients myself -- with excellent outcomes -- and my patients were very very satisfied.
I believe that a well trained FM doc should be confident in identifying and treating most Dermatologic conditions.

Wow... I cannot even talk to you b/c it makes my head hurt. Best wishes (to you and your patients).

FYI -- no one "pops zits"... freezing warts only has a cure rate of 30-40%, hurts like hell, and therefore is performed on fewer than 1 in 5 patients who comes in for warts... and then only if they demand it or we have exhausted the better options.... just because you did not know what you were looking at and thought that it needed a biopsy for diagnosis does not make it so... we quite often do not require a biopsy for the majority of diagnoses... we are not technicians for the referring doc......

 

[Joe Richards]

My vision of "the primary care office of tomorrow" would have to include multiple mid levels and RN's doing the bulk of the counseling, education, information gathering, etc -- and the MD would be responsible for managing, oversight, quality control and assurance, etc... anyone wishing to maintain the current one-on-one MD time would either have to have one of McCain's "gold plated plans" or pay some form of luxury tax / retainer / concierge fee. You simply do not get paid well enough to continue things as they are, and any changes in the reimbursement structure would likely fall short..


I have to say that I don't see that vision at all and I'm a primary care physician.

I actually take offense to that vision. I'm not insulting you I just don't want a specialist telling me what my job should be. I know what my job is.

I don't want to give more power to ANY mid-level. I'm SO MUCH better trained.

The nurse can do education and training. But I get to see the patients. I'm the doctor. "Doctor" not provider. Board Certified MD/DO.

I will supervise and direct care.

The problem with the current system is just as others have said.
Procedures are king right now. Most insurance companies don't pay for advice or time spent with patients taking care of their general needs.

Bottom line is that in every country that primary care is valued the patient outcomes are better. That's a fact.

The post above stated that he can see most derm patients himself. I do to. I refer when I don't know or I think they need a procedure done that I don't do.

I do biopsies, I don't do CABG.

Patients want to be able to go to one place get most of the care done.
It is a medical fact that most primary care doctors can take care of 70% of the patients problems. They may have to send to a specialist every once in a while to adjust meds if the patient is not doing as well at expected.

So, YES primary care pay needs to me much higher, much, much higher.

 

[MOHS_01]

My vision of "the primary care office of tomorrow" would have to include multiple mid levels and RN's doing the bulk of the counseling, education, information gathering, etc -- and the MD would be responsible for managing, oversight, quality control and assurance, etc... anyone wishing to maintain the current one-on-one MD time would either have to have one of McCain's "gold plated plans" or pay some form of luxury tax / retainer / concierge fee. You simply do not get paid well enough to continue things as they are, and any changes in the reimbursement structure would likely fall short..


I have to say that I don't see that vision at all and I'm a primary care physician.

I actually take offense to that vision. I'm not insulting you I just don't want a specialist telling me what my job should be. I know what my job is.

I don't want to give more power to ANY mid-level. I'm SO MUCH better trained.

The nurse can do education and training. But I get to see the patients. I'm the doctor. "Doctor" not provider. Board Certified MD/DO.

I will supervise and direct care.

The problem with the current system is just as others have said.
Procedures are king right now. Most insurance companies don't pay for advice or time spent with patients taking care of their general needs.

Bottom line is that in every country that primary care is valued the patient outcomes are better. That's a fact.

The post above stated that he can see most derm patients himself. I do to. I refer when I don't know or I think they need a procedure done that I don't do.

I do biopsies, I don't do CABG.

Patients want to be able to go to one place get most of the care done.
It is a medical fact that most primary care doctors can take care of 70% of the patients problems. They may have to send to a specialist every once in a while to adjust meds if the patient is not doing as well at expected.

So, YES primary care pay needs to me much higher, much, much higher.

Joe,

I guess that I need to make myself a little clearer -- this vision is not necessarily what I believe it best -- it is the evolutionary direction that I believe the marketplace will force us. I don't particularly like it, but I still fear that is the direction that I believe we all are being taken -- PCP's and specialists alike (it's just that the economic forces will become pressing much earlier in the timeline for cash strapped PCP offices). I did not mean to advocate this model.... much like stating that Obama's tax plan will penalize many physicians... is not an advocation of said plan.

I have argued for years that PCP's could be doing a lot more minor skin procedures; eventually market forces, if allowed to work, would find a balance. Some patients would demand to be seen by "a specialist", some PCP's would be technically great and develop a significant following, and some would suck which would land people in someone else's office. That is the way that medical practices are built.

It is also a fallacy for many to believe that good money cannot be made as a PCP. My good friend who works above me makes anywhere between 25-50k less per year than I do, works one half a day a week less than I do, and spent two years fewer in training than I did. He takes no after hour call (has a FFS afterhour call service), does no hospital work (has an agreement with a hospitalist service), and sees a third less patients than I do. Now how exactly he makes his money I don't know -- I do know that he does not take new MC patients or any MA, though. He is a good doc, with a good rep, and really does not refer me that much other than the time consuming crazies now that I think about it... he freezes AK's, performs biopsies, and apparently performs excisions and destructions... and very few people complain.

I know that I can come across harsh (at least when compared to typical medical folks with their complete aversion to disagreement or conflict), but I really am a fan of PCP's and would like to see them do better financially. I have devoted countless hours working on a project that would allow them to deliver high quality care in a more efficient manner (much in the way that many dermatologists are able to).

 

[MOHS_01]

I also want to say that derm will not come out unscathed either -- we will once again be relegated in large part to taking care of the difficult problems (which we don't really like, they take longer, are more difficult to treat, and are boring as well). PCP's and midlevels will handle the simple and mundane, the quick hitters that generate the bulk of our revenue now. Folks like me will probably perform mostly minor outpatient procedures, which are sitting square on the chopping block with imaging, cutting our knees out from under us as well. Basically I see the system evolving to where MD's are more managerial and technical, performing procedures and providing oversight to make sure that midlevels are performing adequately. Reimbursement levels will dictate that we do so, else we accept an annual income that is not commissurate with our education.... and I don't like it any more than you do.

 

[Joe Richards]

Again, my post was not meant to be rude. But I had to make clear that PCP's don't really want the model you mentioned.

As physicians (all specialties) we have a golden opportunity right now to shape medicine the way we want.

We just need to get together and speak up, be tough and not back down.

I've mentioned before that I believe the only true/real way physicians can co-exist with insurance companies is by negotiating balance billing contracts.

Physicians should be able to set their own prices and be able to increase their prices based on the average annual inflation rates if they choose.

If an insurance company wants to pay 20 dollars per visit, that is between the patient and the insurance company. (customer and company)

When they come to me I may charge 100 dollars for that visit. So they pay me 80 in the office.

If they don't like that then they can take it up with their insurance company. I'm not affiliated with them.

If I don't like the way an insurance company pays I just drop them.

Either way I get paid and competition between medical offices will keep prices reasonable. Not low but competitive and reasonable.

Insurance will be more focused on Hospital pay and catastrophic care and less focused on outpatient pay for procedures and office visits.

This will reduce premiums, the patients will get better care and primary care will survive and succeed.

Balance billing is the future. Its either that or the British system of socialized medicine with some individuals who can afford private insurance.

Joe,

I guess that I need to make myself a little clearer -- this vision is not necessarily what I believe it best -- it is the evolutionary direction that I believe the marketplace will force us. I don't particularly like it, but I still fear that is the direction that I believe we all are being taken -- PCP's and specialists alike (it's just that the economic forces will become pressing much earlier in the timeline for cash strapped PCP offices). I did not mean to advocate this model.... much like stating that Obama's tax plan will penalize many physicians... is not an advocation of said plan.

I have argued for years that PCP's could be doing a lot more minor skin procedures; eventually market forces, if allowed to work, would find a balance. Some patients would demand to be seen by "a specialist", some PCP's would be technically great and develop a significant following, and some would suck which would land people in someone else's office. That is the way that medical practices are built.

It is also a fallacy for many to believe that good money cannot be made as a PCP. My good friend who works above me makes anywhere between 25-50k less per year than I do, works one half a day a week less than I do, and spent two years fewer in training than I did. He takes no after hour call (has a FFS afterhour call service), does no hospital work (has an agreement with a hospitalist service), and sees a third less patients than I do. Now how exactly he makes his money I don't know -- I do know that he does not take new MC patients or any MA, though. He is a good doc, with a good rep, and really does not refer me that much other than the time consuming crazies now that I think about it... he freezes AK's, performs biopsies, and apparently performs excisions and destructions... and very few people complain.

I know that I can come across harsh (at least when compared to typical medical folks with their complete aversion to disagreement or conflict), but I really am a fan of PCP's and would like to see them do better financially. I have devoted countless hours working on a project that would allow them to deliver high quality care in a more efficient manner (much in the way that many dermatologists are able to).

 

[MOHS_01]

Again, my post was not meant to be rude. But I had to make clear that PCP's don't really want the model you mentioned.

As physicians (all specialties) we have a golden opportunity right now to shape medicine the way we want.

We just need to get together and speak up, be tough and not back down.

I've mentioned before that I believe the only true/real way physicians can co-exist with insurance companies is by negotiating balance billing contracts.

Physicians should be able to set their own prices and be able to increase their prices based on the average annual inflation rates if they choose.

If an insurance company wants to pay 20 dollars per visit, that is between the patient and the insurance company. (customer and company)

When they come to me I may charge 100 dollars for that visit. So they pay me 80 in the office.

If they don't like that then they can take it up with their insurance company. I'm not affiliated with them.

If I don't like the way an insurance company pays I just drop them.

Either way I get paid and competition between medical offices will keep prices reasonable. Not low but competitive and reasonable.

Insurance will be more focused on Hospital pay and catastrophic care and less focused on outpatient pay for procedures and office visits.

This will reduce premiums, the patients will get better care and primary care will survive and succeed.

Balance billing is the future. Its either that or the British system of socialized medicine with some individuals who can afford private insurance.

AMEN.... I 100%, absolutely, wholeheartedly agree that balance billing is an ideal solution... no more contracts with 3rd party payors, physicians and patients would reclaim the control over the discussion. I really don't ever see it flying with the folks at MC, though...

Unfortunately, though, the counter argument would be that history has shown us that this form of system does little for cost control -- it merely shifts the costs from one party to another. Either there would be some inherent rationing within the system based upon ability to pay or their would be poorly controlled cost escalation.

I really do like the way that you think though. My thought on the future assumed that we do not regain control of the discussion and are forced to work within the confines of the system that is forced upon us.

 

[Old_Mil]

I heard a story on NPR this morning that made me wonder:

http://www.npr.org/templates/story/story.php?storyId=95720324

Is the exaltation of procedural and specialist medicine responsible for the overwhelming cost of the US healthcare system?

In the study mentioned in the NPR piece, they found only about 40% of patients receiving angioplasty had ever had a stress test first, even though in many cases, angioplasty is LESS effective than optimal medical management.

Our system is set up to financially reward proceduralists and specialists, and those are the LEAST cost effective ways to solve medical problems.

Thoughts?

I don't think so. In my opinion, there are three things that are causing the medical system to collapse:

(1) Malpractice Lawsuits. Nuff said.

(2) The advent of for profit medical institutions. With the possible exception of pharmaceutical companies and medical device manufacturers, there should be an absolute ban on for profit medical practice. No for profit medical schools, no for profit hospitals.

(3) A business management mindset that is dedicated not just to improving the bottom line as much as possible, but insuring that the majority of corporate profits are concentrated in the hands of the fewest number of people at the top of the corporate ladder. This means part time work, outsourcing of jobs, benefitless jobs, and the shifting of health insurance costs to individual employees. Keep in mind that for the VP and up set in every American corporation, there is no health care crisis.

 

[andwhat]

Wow... I cannot even talk to you b/c it makes my head hurt. Best wishes (to you and your patients).

FYI -- no one "pops zits"... freezing warts only has a cure rate of 30-40%, hurts like hell, and therefore is performed on fewer than 1 in 5 patients who comes in for warts... and then only if they demand it or we have exhausted the better options.... just because you did not know what you were looking at and thought that it needed a biopsy for diagnosis does not make it so... we quite often do not require a biopsy for the majority of diagnoses... we are not technicians for the referring doc......

Almost anything that a Dermatologist can do, a well trained PCP doc can do the same, or even better.
I even tried to refer my patients to Derm docs, but they were convinced that I knew what I was doing -- because I could not only make the accurate diagnosis, but my treatment modality was right on point.
Am I saying that I can diagnose and treat any Dermatologic condition? No -- but I will put money on the fact that I can -- for the majority of Dermatologic diagnoses.
I am thinking of opening up a side gig one day, Derm clinic / Urgent Care.
I know of a few primary care docs doing that in Chicago -- quite lucrative.

 

[sophiejane]

Please, keep it collegial.

This is not a playground and we are not 4th graders.

Carry on.

 

[Joe Richards]

AMEN.... I 100%, absolutely, wholeheartedly agree that balance billing is an ideal solution... no more contracts with 3rd party payors, physicians and patients would reclaim the control over the discussion. I really don't ever see it flying with the folks at MC, though...

Unfortunately, though, the counter argument would be that history has shown us that this form of system does little for cost control -- it merely shifts the costs from one party to another. Either there would be some inherent rationing within the system based upon ability to pay or their would be poorly controlled cost escalation.

I really do like the way that you think though. My thought on the future assumed that we do not regain control of the discussion and are forced to work within the confines of the system that is forced upon us.

It does shift the cost. But, the cost will shift no matter what we do.

In a British system, the cost will shift to the tax payer. In a balance bill system the cost will shift to the individual consumer (the tax payer).

The difference is that they can choose when and with whom to get treatment from and if it is an elective procedure can choose when to do it.

If we move towards the mid-level system, there will less of a need for MD's because we will be more in supervisory role.

This is not a simple subject and I know that we are moving towards a single party payer system regardless of who wins this election. It is not in their control. The healthcare system will collapse.

That is why it is the perfect time for Doctors to stand up, unite and make a stand on how they want things to be run.

If doctor x is making a good living he is going to give charity care and not worry as much about it.

 

[Joe Richards]

I don't think so. In my opinion, there are three things that are causing the medical system to collapse:

(1) Malpractice Lawsuits. Nuff said.

(2) The advent of for profit medical institutions. With the possible exception of pharmaceutical companies and medical device manufacturers, there should be an absolute ban on for profit medical practice. No for profit medical schools, no for profit hospitals.

(3) A business management mindset that is dedicated not just to improving the bottom line as much as possible, but insuring that the majority of corporate profits are concentrated in the hands of the fewest number of people at the top of the corporate ladder. This means part time work, outsourcing of jobs, benefitless jobs, and the shifting of health insurance costs to individual employees. Keep in mind that for the VP and up set in every American corporation, there is no health care crisis.

If you don't set up medical institutions as for profit then you have to define how much a doctors salary is worth.

How much are you worth? How much is a mid-level worth? Really worth.

If there is no profit is the Govt. going to pay my tuition for medical school?

Who will decide to assign PCP pay and specialist pay?

And why should pharmaceutical companies and medical device manufactures be exempt? Aren't they working (at least in theory) for the better of mankind?

I agree that for profit institutions can and frequently fall to greed but there are non-profit organizations where the CEO has the biggest, house on the hill.

He has an MBA. That's two years after undergrad and very little sleepless nights.

Maybe the doctor should be paid the big non-profit salaries. After all if the MBA gets sick and can't run the non-profit, it will be the doctor who is going to possibly save his life.

 

[Old_Mil]

I am thinking of opening up a side gig one day, Derm clinic / Urgent Care.
I know of a few primary care docs doing that in Chicago -- quite lucrative.

Start a Nighthawk-like service for Derm. PCP goes in, snaps a picture of the lesion with his iPhone, and gets an email back with the read... 🙂

 

[Faebinder]

A few years ago I got a call from a friend in law school. She was cramming for a final in the school library when she stood up from her desk and bumped her elbow. She became light headed and had a brief syncopal episode. She was out for a few seconds. EMS was called by the library staff; she had normal vitals and screening neuro exam. She declined a trip to the ER and called me later that night. I told her it sounded like vasovagal syncope, but she should see her PCP if she was concerned.

Her husband, who is a business consultant in a hospital decided he could do a little better, and pulled some strings to get her in to see the chair of the department of neurology at the medical school associated with the hospital. Three days later, after a sleep deprived EEG, CT Head, MRI Head, Cardiology consult, labs, etc, etc, she was discharged with a diagnosis of .......... vasovagal syncope.

I'm not at all mudslinging or playing Monday morning quarterback. I'm sure that neurologist is a very smart guy. There are plenty of people around that can point out my mistakes, or point out a needless a MRI ordered by an FP. However, if you have a hammer then the world is a nail. Or if you have a new cardiac CT in your office, the world is a cholesterol laden LAD. Our top heavy system is ONE of the big problems with US healthcare.

Was thinking about your case.... The opinion you stated over the phone is easy to defend in court.... no tests and no responsibilities.. she is not your patient.. a friend who called you. If she was a random person who came to your office... and told you the exact same story.. would you have simply said vasovagal syncope.. that's $50 call in the next patient? I somehow doubt it.

Somewhere down the line, the level of responsibility changed... the level of responsibility increases when the person is your patient in the office and goes even higher if the patient is your patient in the hospital. Inaccuracy becomes a lot less defendable... "Dr. EdibleEgg, please tell the court why you DIDNT order a CT scan of the patient's head."

 

[CambieMD]

Fractured healthcare is expensive and inefficient healthcare.

PCPs should do more for our patients and save them the often unnecessary expense (and risks) of procedure-laden specialist-heavy, fractured medical care.

We need to be handling more and referring less. The more I do this, the more I realize how much of this I can do. Obviously, when you need a surgeon or ID or neuro, you need them. But I think, as a whole, we refer way too much.

Are specialists seeing only truly appropriate referrals? I don't think so. That's why they hire midlevels, which is terribly ironic. You go to the specialist and all you see is a nurse. You'd be better off seeing an actual doctor at your PCP's office. I think cardiologists (or their midlevels) manage a lot of very routine CHF and hypertension. I think dermatologists (or their midlevels) see a lot of mild-moderate acne and eczema and routinely do biopsies that any FP that half-paid attention in residency could handle.

{I'm ready for the burning arrows, I know they are coming.}

We have the most expensive medical system in the world (except perhaps for Japan, but theirs is heavily subsidized)...and I maintain that it is one of the least efficient. For the amount of money we spend on healthcare each year, there is NO reason why every American can't have basic healthcare. Or maybe there is. Maybe it's because so many people think you have to go to a gastroenterologist for your stomach ache or a neurologist for your headaches. And they end up getting MRIs and scopes and procedures they wouldn't have needed if someone would have taken the time to do a decent H&P and a thorough physicial.

It is stunning the number of clues many specialists miss on basic histories because they are so narrowly focused. The lady with very obviously non-neurologic syncope gets an MRI and an EEG and a neuro consult when all she really needs is orthostatic BPs and someone to really sit down and listen to her story.

And we all know the old joke (that's not really a joke) that everyone who walks through the doors of the ED gets a head CT. They aren't ordering them because they are all truly indicated or even because the doctors think they will get sued. They order them because it's faster and easier than doing a complete, focused history and physical. When you are getting paid per patient, it's no wonder you'd rather run everyone through a machine than actually sit down and try to figure out what's wrong with them.

The American medical system is in trouble not because of specialists but because of waste, fat, inefficiencies.We fail to appreciate the important role of preventative medicine and advocating healthy lifestyles.

It cost us too much to deliver our product. India can perform complicated surgical procedures for a fraction of the cost.

I was a PCP. Now I am a specialist. When I was an FP doc I worked to keep my overhead down. Unfortunately the cost of medical care in this country is out pacing everything else and the quality of that care is often poor.

I do not think that the answer is nationlized health care. We have to get a handle on cost.

The US consumes something like 50% of the illicit drugs produced. The medical toll is enormous. Look obesity in this country. We need drives to reduce the rates of obesity.

Cambie

 

[andwhat]

The American medical system is in trouble not because of specialists but because of waste, fat, inefficiencies.We fail to appreciate the important role of preventative medicine and advocating healthy lifestyles.

It cost us too much to deliver our product. India can perform complicated surgical procedures for a fraction of the cost.

I was a PCP. Now I am a specialist. When I was an FP doc I worked to keep my overhead down. Unfortunately the cost of medical care in this country is out pacing everything else and the quality of that care is often poor.

I do not think that the answer is nationlized health care. We have to get a handle on cost.

The US consumes something like 50% of the illicit drugs produced. The medical toll is enormous. Look obesity in this country. We need drives to reduce the rates of obesity.

Cambie

excellent post agreed 100%

The test is wicked detailed sometimes. Harder than the in service training examination in my opinion.

 

[andwhat]

Start a Nighthawk-like service for Derm. PCP goes in, snaps a picture of the lesion with his iPhone, and gets an email back with the read... 🙂

that would be amazingly cool. Expensive I will bet for that Derm consult ;-)
However we are not allowed to do it because of HIPAA violations, we were thinking about doing it while on call.
The first year would snap a phone picture from the ER, and send it to me at home, and I would try and make the diagnosis.
I would imagine that we would have faced some serious penalties for that though ;-)

 

[lowbudget]

I was a PCP. Now I am a specialist. When I was an FP doc I worked to keep my overhead down. Unfortunately the cost of medical care in this country is out pacing everything else and the quality of that care is often poor.

I do not think that the answer is nationlized health care. We have to get a handle on cost.

Absolutely. In all other businesses, costs can be passed to the consumer (look at the airlines...).

Except in health care, where there's so much price inelasticity. Patients don't know how much their health care is worth because insurance distorts the market... which is why patients scoff at the idea of paying for health care.

Super-specialists (like neonatologists) can demand any price they want and insurance companies will pay. In primary care, insurance companies set the price and doctors have to figure out how to control their costs.

I mean, people want "everything possible" to revive an barely viable preemie, but scoff at the idea of paying for Gardasil.

I'm a proponent for price transparency, pay-for-quality, stripping away sovereign immunity from Medicare/Medicaid (i.e. the right to sue the federal government), and taking away tax advantage for employer-sponsored health insurance. I like the *original* Clinton Plan with "managed competition" where consumers would buy health insurance through HIPC's (health insurance purchasing cooperatives) where they can benefit from risk pooling. And allowing to buy it from a pre-tax basis.

Insurance companies need to start answering to patients/consumers, not the HR department of business (large ones particularly... small business get screwed when it comes to health insurance).

We need to form a Medical Court, just like Bankruptcy or Tax Courts, where people who understand medicine can determine whether or not a doctor is negligent. A true "jury of your peers" and not Joe the (unlicensed) Plumber; in the true spirit of a profession that regulates itself.

Price & quality transparency, with consumer choice with consumer protection, may screw over some doctors; but we are physicians and patients some day, so I'm not looking for an advantage. I'm looking for fairness. Call it capitalism... Call it socialism... I don't care because those words mean nothing to me. I call it Common Sense.

And thus all of us bear the responsibility: patients, doctors, lawyers, businesses, insurance companies, government...

 

[deleted87716]

If she was a random person who came to your office... and told you the exact same story.. would you have simply said vasovagal syncope.. I somehow doubt it.

I would've.

 

[deleted87716]

However we are not allowed to do it because of HIPAA violations

No, it's not.

I've taken photos of skin disorders and e-mailed them to derm colleagues for an opinion more than once. I just don't include any personally-identifying patient information in the e-mail (only because e-mail isn't entirely secure, and I'm not using encryption). No HIPAA violation there.

Incidentally, it's not a HIPAA violation to consult a colleague about a patient, whether it's by phone, fax, e-mail, or over lunch.

 

[deleted87716]

My vision of "the primary care office of tomorrow" would have to include multiple mid levels and RN's doing the bulk of the counseling, education, information gathering, etc -- and the MD would be responsible for managing, oversight, quality control and assurance, etc...

No way in hell. I don't let my M.A.'s write down anything past the chief complaint. The rest is my job, and it always will be. Taking a patient's history is an art, and arguably the most important part of the entire encounter. You don't delegate that.

I don't try to do everything myself, though. I use diabetes educators, nutritionists, etc. frequently, but I have no desire to supervise or employ them.

"Overhead" is overwhelmingly a function of revenue generated, which is often physician dependent as much as it is specialty dependent.

No way. If that were the case, primary care would have just about the lowest overhead of any specialty, not the highest. Overhead is based on what we're expected/required to do by patients and third-party payers, not the amount of revenue we're generating. That's why four full-time equivalents per doctor is the industry average in primary care.

And, no...that's not the way it ought to be.

 

[MOHS_01]

Blue,

You lost me, buddy. My statement in no way constitutes a commentary on the reimbursement structure that we have today -- facts are facts and math is math -- and by virtually anyone's definition overhead is the cost associated with providing a service, which is a simple mathematical calculation based upon revenue generated minus cost incurred divided by revenue... a good deal of our costs (the vast majority in my practice) are fixed in nature (and includes staffing requirements), and therefore the variable that falls most within our control is revenue generation.

I understand everyone's ire with delegation of "crucial" tasks -- no one ever said that you could not verify and expound upon data already gathered, which is a more MD time efficient operational method. As a matter of fact, in order to satisfy correct coding initiative requirements the physician must verify the HPI... I am just saying this: if PCP's want to increase their earnings within the confines of the system that we have in place, changes will have to be made, many of which will not be considered palatable by traditional standards.

I still like my idea of having add-on CPT codes for patient education, preventative, and wellness services and boosting high intensity E&M fees as a means to help level the playing field.

I also believe that (internists and FP's, especially) are thinking small and missing out on opportunity -- I would view the diabetic educators, nutritionists, even personal trainers as ancillary staff, and revenue generators for the practice. It seems that everyone is espousing the medical home concept, yet many want to live in an efficiency loft rather than embracing the concept to its full potential.

As long as we continue to be stuck in the rut of backward thinking (myself and my colleagues included) that confines us to nothing more than a skilled labor status, where the only revenue generating hands in the office are those of the physician... and the only $$ that the doc (who should own, manage, direct, and provide the framework for the workings and feel for the enterprise) sees is whatever is left over at the end of the day from his/her services (after everyone else gets paid), we will undeniably continue down this road of stagnant or declining pay...

As an aside, general, medical dermatology has the same overhead as primary care as a general rule -- approximately 55%. In practices that provide a strong mix of surgery, path, with or without cosmetics, our typical overhead runs anywhere from a low of 40% (rare) to 50% (most common according to AAD figures)... with MGMA "good" performers holding at around 45%.

 

[MOHS_01]

I should also say that in my *problematic* "primary care office of tomorrow" the MD would still be responsible for seeing the medically complex patients, many of the new patients, etc -- I did not intend to imply a strictly supervisory role -- but I would free them from routine follow-ups, etc.