Been brought up before, but worth another look...

[Red Beard]

Found this article about retail clinics today and thought it was an interesting analysis.

I'm still holding onto an (admittedly naive) plan of opening a small private practice down the road. There might not be much of a demand anywhere in the country if every Walmart or Target has a clinic in it.

Comments?

https://www.do-online.org/index.cfm?PageID=aoa_nwsretailclinics

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Members don't see this ad.

 

[deleted87716]

I'm still holding onto an (admittedly naive) plan of opening a small private practice down the road. There might not be much of a demand anywhere in the country if every Walmart or Target has a clinic in it.

Any doctor who can't offer more than what you can get at one of these clinics isn't much of a doctor.

 

[Red Beard]

Agreed, however, it seems to me that a lot of the patients who will come to my office in the future will have problems that COULD be addressed at these kind of clinics. From the patient's perspective, I could see the appeal of these kind of places--if I have strep or my kid has an ear infection...walk in and get my appointment and my antibiotic with few hassles...

I just wonder how much business that might take away from FPs in areas where the operating margin is already a little tight. It seems like there is a Walmart in or near every town these days!

 

[MacGyver]

Listen very carefully to the tone of that article.

Its all about doctors trying to "adjust" their marketing to take advantage of or not get hurt by these minuteclinics.

Now you tell me. Does that sound like the kind of tone you would hear if there were a true doctor shortage? HELL NO. If there were a real shortage, then docs wouldnt give a damn about hte minute clinics and just laugh.

The fact that the DO associations are worried about minute clinics tells me that the idea of a doctor shortage is nothing more than made up bull****.

 

[awdc]

Listen very carefully to the tone of that article.

Its all about doctors trying to "adjust" their marketing to take advantage of or not get hurt by these minuteclinics.

Now you tell me. Does that sound like the kind of tone you would hear if there were a true doctor shortage? HELL NO. If there were a real shortage, then docs wouldnt give a damn about hte minute clinics and just laugh.

The fact that the DO associations are worried about minute clinics tells me that the idea of a doctor shortage is nothing more than made up bull****.

I have a different perspective on this. I think the fact that there are non-physician clinicians providing care traditionally provided by physicians is a sign of a doctor shortage. If there were no doctor shortage, there wouldn't be an increasing market for midlevels.

 

[Red Beard]

Wal-Mart et. al. have the power and the resources to squeeze clinics into even the most saturated markets. A physician shortage sweetens the pot for these mega-corporations, but it is not required for them to have clout.

Secondly, it seems to me one of the biggest reasons there is a shortage of physicians working in rural areas is because its hard for them to make any money out there. With such a high percentage of people uninsured or on medicare/medicaid, docs have to carry a very full schedule to make it. Having a Wal-clinic siphoning off a chunk of your bread and butter cases can't help.

 

[flighterdoc]

Wal-Mart et. al. have the power and the resources to squeeze clinics into even the most saturated markets. A physician shortage sweetens the pot for these mega-corporations, but it is not required for them to have clout.

Secondly, it seems to me one of the biggest reasons there is a shortage of physicians working in rural areas is because its hard for them to make any money out there. With such a high percentage of people uninsured or on medicare/medicaid, docs have to carry a very full schedule to make it. Having a Wal-clinic siphoning off a chunk of your bread and butter cases can't help.

And what will happen (do you think) when a mid-level gets sued, and the trial lawyer gets Wal Mart involved? How many such suits will Wal Mart defend until they have said enough?

 

[Faebinder]

And what will happen (do you think) when a mid-level gets sued, and the trial lawyer gets Wal Mart involved? How many such suits will Wal Mart defend until they have said enough?

Indeed, that's a key issue.... and believe me it will be easy for a lawyer to get expert witnesses considering they are physicians with higher education/training levels vs mid-levels.

Yet I dont feel this will hinder Wal Mart... what I believe they will do is exactly what the article said... contract with a physician who is desperate for more cash to come and supervise the PA/NP running the clinic.

At this rate.. Wal-Mart might as well buy some hospitals.... heh.

 

[bkpa2med]

Wal-Mart et. al. have the power and the resources to squeeze clinics into even the most saturated markets. A physician shortage sweetens the pot for these mega-corporations, but it is not required for them to have clout.

Secondly, it seems to me one of the biggest reasons there is a shortage of physicians working in rural areas is because its hard for them to make any money out there. With such a high percentage of people uninsured or on medicare/medicaid, docs have to carry a very full schedule to make it. Having a Wal-clinic siphoning off a chunk of your bread and butter cases can't help.

I was actually reading the NY Times a few weeks ago and it had an article about a doc in a group rural practice. It specifically stated that in urban city areas a doc would get reimbursed ~$30 for a well child visit. In a rural area the reimbursement is ~$80 due to the need.

 

[Faebinder]

I was actually reading the NY Times a few weeks ago and it had an article about a doc in a group rural practice. It specifically stated that in urban city areas a doc would get reimbursed ~$30 for a well child visit. In a rural area the reimbursement is ~$80 due to the need.

You ever think of it the other way? Meaning both the urban and the rural should be reimbursed $100 but the rural only gets jipped for $20 while the urban gets jipped for $70? Collectable Accounts are a significant amount of every physician's income... Take it with a grain of salt until you see detailed evidence.

 

[deleted87716]

And what will happen (do you think) when a mid-level gets sued, and the trial lawyer gets Wal Mart involved? How many such suits will Wal Mart defend until they have said enough?

The clinics are not owned by Wal-Mart. The four companies that Wal-Mart has contracted with (RediClinic, Quick Quality Care, Solantic, and Memorial Health) simply lease the space.

 

[RuralMedicine]

I was actually reading the NY Times a few weeks ago and it had an article about a doc in a group rural practice. It specifically stated that in urban city areas a doc would get reimbursed ~$30 for a well child visit. In a rural area the reimbursement is ~$80 due to the need.

Likely the rural practitioner was getting enhanced reimbursement as part of a FQHC/RHC enhanced medicaid reimbursement scenario. I practice in an underserved rural community and do not get anywhere near that for well child visits from anyone.

 

[flighterdoc]

The clinics are not owned by Wal-Mart. The four companies that Wal-Mart has contracted with (RediClinic, Quick Quality Care, Solantic, and Memorial Health) simply lease the space.

Sure, thats the theory. And it works, until some slimeball trial lawyer (sorry for being redundant) somehow convinces 12 people too stupid to get out of jury duty that since Wal Mart made the space available, and advertises the service, and decides what group to rent to, that they're responsible.

 

[sophiejane]

Likely the rural practitioner was getting enhanced reimbursement as part of a FQHC/RHC enhanced medicaid reimbursement scenario. I practice in an underserved rural community and do not get anywhere near that for well child visits from anyone.

Is your clinic a federally qualified rural health clinic (or whatever the official name is)? I understood that once you got that status, your medicare and medicaid reimbursements would increase.

As I've understood it, simply setting up a practice in a rural area does not mean you get increased reimbursements from the government. You have to jump through the bureaucratic hoops first.

 

[deleted87716]

Sure, thats the theory. And it works, until some slimeball trial lawyer (sorry for being redundant) somehow convinces 12 people too stupid to get out of jury duty that since Wal Mart made the space available, and advertises the service, and decides what group to rent to, that they're responsible.

I suspect Wal-Mart employs their own risk management folks who already thought of that.

There's probably about as much chance of them being successfully named in a malpractice suit as the landlord in my medical office building.

If there's any legal exposure for them, I think it's in encouraging sick/contagious people to come to a crowded public place for healthcare. In a flu pandemic, for example, this would be a really bad idea.

 

[RuralMedicine]

Is your clinic a federally qualified rural health clinic (or whatever the official name is)? I understood that once you got that status, your medicare and medicaid reimbursements would increase.

As I've understood it, simply setting up a practice in a rural area does not mean you get increased reimbursements from the government. You have to jump through the bureaucratic hoops first.

I'm in private practice and not currently an FQHC or RHC. Although it is something I'm considering because of the benefits to patients if I were to go that way (expanded VFC eligibility and at cost prescription coverage). Practitioner benefits include tort coverage, and in some cases enhanced reimbursement [although from crunching the numbers if I did it in solo practice it wouldn't change my reimbursement significantly--if I hired an OB, and a surgeon then it would].

You're mostly correct in your second statement. Although Medicare does provide a lump sum payment to Medicare providers in underserved areas. I suppose you can also potentially negotiate better contracts with commercial insurers although I have not been anywhere near as successful with this as Kent alludes he/his group have on the Medicare thread. In actuality in rural practice I think you lose some of your bargaining power if you strive to serve the community and therefore feel somewhat obligated to take certain payer sources that are loss leaders largely because it is there and your patients do not have anything else. Dropping Medicaid would be a great financial thing for me but I'd be turning away patients and at the moment I can't/won't do that.

 

[deleted87716]

I suppose you can also potentially negotiate better contracts with commercial insurers although I have not been anywhere near as successful with this as Kent alludes he/his group have on the Medicare thread. In actuality in rural practice I think you lose some of your bargaining power if you strive to serve the community and therefore feel somewhat obligated to take certain payer sources that are loss leaders largely because it is there and your patients do not have anything else.

Pretty much. If you're the only game in town, you're basically stuck, unless you want everyone to hate you. Without the ability to control your payor mix, your only options to improve your bottom line are probably in the realm of expense control and ancillary services.

There are limits to how far you can go with that, however, which is probably why you hear more stories about rural docs in financial crisis than you do those in urban or suburban areas.

 

[sophiejane]

you hear more stories about rural docs in financial crisis than you do those in urban or suburban areas.

You do? Do tell....

The rural docs I know are all doing very well. I'm sure there are those who aren't, but I sure haven't met any so far.

I'm not being cheeky, I really would like to hear those stories so I can learn how not to do what they did.

 

[RuralMedicine]

Pretty much. If you're the only game in town, you're basically stuck, unless you want everyone to hate you. Without the ability to control your payor mix, your only options to improve your bottom line are probably in the realm of expense control and ancillary services.

There are limits to how far you can go with that, however, which is probably why you hear more stories about rural docs in financial crisis than you do those in urban or suburban areas.

To an extent rural medicine (at least in a poor rural community) becomes as much of a calling as a career. One thing that does I think help me a little financially is that I do a significant amount of inpatient work and I suppose it cross subsidizes my office practice some. Of course given that I practice in a community where hospitalists don't exist there would probably be an obligation to do hospital work even if it wasn't financially rewarding. Of course I also allow self-pay patients to do a sliding fee scale and that certainly isn't financially rewarding.

 

[RuralMedicine]

You do? Do tell....

The rural docs I know are all doing very well. I'm sure there are those who aren't, but I sure haven't met any so far.

I'm not being cheeky, I really would like to hear those stories so I can learn how not to do what they did.

Perhaps it would make more sense to connect with the rural practices that are doing well financially and see how they do it and then adapt their model to fit your own practice style. There are things I could do that would improve my practice financial situation that I choose not to either based on my values and ethics or just personal preference.

 

[flighterdoc]

I suspect Wal-Mart employs their own risk management folks who already thought of that.

There's probably about as much chance of them being successfully named in a malpractice suit as the landlord in my medical office building.

If there's any legal exposure for them, I think it's in encouraging sick/contagious people to come to a crowded public place for healthcare. In a flu pandemic, for example, this would be a really bad idea.

Sure, and do doubt they have calculated the cost/benefit ratio and know how many suits they can suffer.

Good point about the crowds, though...

 

[deleted87716]

The rural docs I know are all doing very well...I really would like to hear those stories so I can learn how not to do what they did.

I'm just thinking of all the stories in the press (lay and medical) about the current reimbursement situation in primary care. Many of them have focused on the plight of certain rural physicians, as (noted recently by RuralMedicine herself) they're frequently obligated to accept all comers, including Medicaid and other lowball payors, for the good of their community. This can have a profound effect on a practice's bottom line. Our area paper recently carried a story about a local internist who was forced to close his practice due to economic pressures. He had a largely Medicare/Medicaid patient panel. It got the attention of quite a few of my patients, so it served a purpose, I suppose.

That being said, there are certainly plenty of rural medicine success stories, too. It's worth noting that that the press generally tends to over-report bad news, which can lead people to believe things are worse than they are, or that it's the same for everybody.

 

[RuralMedicine]

That being said, there are certainly plenty of rural medicine success stories, too. It's worth noting that that the press generally tends to over-report bad news, which can lead people to believe things are worse than they are, or that it's the same for everybody.

Actually I think that our healthcare system is going to break further before we try to fix it. I think this will impact more in rural/ other underserved communities. Although in non rural underserved communities there are usually adequately developed resources they are just cost prohibitive for much of the population. You may live in the slums in a city where you can not find a pediatrician who takes medicaid but when your child is truly sick there is a hospital with EM trained providers in the ED and pediatricians who are probably obligated by the hospital to take a certain amount of unassigned admits. I'm not saying this is an ideal situation because I don't believe it is but if you're living in a rural area where you have no providers (the combination of poor payer mix, higher malpractice costs and the recent closing of the hospital led them to all establish practices elsewhere) and your community hospital which was the only one in the county closed, and you are almost two hours from the nearest hospital and you wait hoping it will get better because after all gas is nearly three dollars a gallon and your neighbor's car isn't that reliable anyway and then your neighbor says that the baby "really looks bad we should call 911" which happens but now that your EMS squad is making 3-4 hours runs because your local hospital closed there isn't an ambulance available as all three (which is a lot for a rural community to have in the first place) are out.

 

[deleted87716]

Actually I think that our healthcare system is going to break further before we try to fix it. I think this will impact more in rural/ other underserved communities.

Unfortunately, I think you're right. That doesn't mean that people should avoid rural medicine, or primary care, for that matter. Individual primary care physicians, for the most part, can and will do what it takes to survive economically. It's the patients, ultimately, who will suffer the most. Certain specialties, such as emergency medicine, will find themselves increasingly on the receiving end of the problem. Far from being a temporary "fix," this will exacerbate the situation even more.

I don't have the answers any more than anyone else does, however. There's no single solution to the problem that I can see.

 

[RuralMedicine]

Unfortunately, I think you're right. That doesn't mean that people should avoid rural medicine, or primary care, for that matter. Individual primary care physicians, for the most part, can and will do what it takes to survive economically. It's the patients, ultimately, who will suffer the most. Certain specialties, such as emergency medicine, will find themselves increasingly on the receiving end of the problem. Far from being a temporary "fix," this will exacerbate the situation even more.

I don't have the answers any more than anyone else does, however. There's no single solution to the problem that I can see.

I think that ultimately at some point we will be forced to fix our broken health care system because it will touch enough people or people close enough to our legislators that they realize there truly is a problem. If the rural hospital in the county I practice in closes (which is probably going to be reality in less than a year in spite of efforts on the part of several physicians in this community to prevent that) I really worry about what will happen. But we're a small rural county and it's not going to be much of a blip on the global radar.

*One disclaimer: Our situation is a little more complex because I do believe that transitioning to critical access would probably (at least temporarily until things get worse) save our hospital but our current administration refuses to consider that possibility (our current CEO "would rather see the doors close permanently"). So I suppose I can't blame all the problems here on our broken health care system, however, that doesn't really change things for our patients.

 

[deleted87716]

I think that ultimately at some point we will be forced to fix our broken health care system because it will touch enough people or people close enough to our legislators that they realize there truly is a problem.

Since we're on the subject, I'll share my thoughts on our "broken" system.

One of the biggest problems, IMO, is the fact that our current system insulates patients from the true costs of their care, and places a "middleman" (the insurance company or government) between doctor and patient. Secondarily, there is generally no financial incentive for patients to lead healthier lives, aside from the potential cost of medications, etc. to eventually treat illnesses of neglect. IMO, the current move towards "pay for performance" is misguided, as it incents the wrong people. Paying doctors based on the health of their patients is as backwards as direct-to-consumer drug advertising. Ultimately, these schemes serve the needs of their architects (insurance companies pay less for care, and pharmaceutical companies sell more drugs) at everyone else's expense.

My wife's health insurance gives her a discount for maintaining certain health parameters within normal limits (weight, body fat, exercise tolerance, BP, cholesterol, etc.) She gets an annual "insurance physical" (basically vital signs, lab work, and a ride on a stationary bike) in order to continue to qualify for the discount. AFAIK, smokers aren't even eligible for the discount in the first place. If any of the measured parameters exceed the limits, she'd be put on "probation" for a few months and would lose her discount if she didn't get things back in line pronto. Personally, I think this is an interesting concept, and deserves more exposure.

I also think health insurance policies should be more like life insurance policies, in that you would purchase them when you're young and healthy, and they'd be portable between jobs. Employers could still provide "health benefits" by giving employees an allowance towards coverage, much like an automobile allowance. I have a hard time believing that insurance companies couldn't market products like that. They just don't have any incentive to do so, as it's easier to negotiate bulk contracts with large employers than it is to sell to individuals.

Paperwork needs to be simplified, as well. A significant percentage of overhead in any medical practice goes towards billing and collecting money from insurance companies. It's absolutely nuts, when you get right down to it, and needlessly increases the cost of providing care. Many practices are shifting some of this burden to patients (e.g., not filing secondary insurance), and with the move towards health savings accounts and such, I think this is going to become more commonplace in the future. Many practices are also charging for certain types of uncompensated work, like form completion, and I expect this to become more routine. Patients generally act as if we're on retainer already, even though most of us are not compensated in that fashion. It might make sense in the future for this relationship to be made "official" (even if the "retainer" or "administrative fee" was fairly minimal.) A small ($2-5/month per patient) administrative fee could add a significant amount to a struggling practice's bottom line.

I'm not in favor of a single-payor system. However, I do think that the government could sponsor some form of "bare bones" coverage that would allow every American to receive certain basic services. Private insurance could be purchased to upgrade coverage, if desired. Obviously, the same reimbursement issues that we currently face with Medicare and Medicaid would apply to any form of government-sponsored coverage. If the money isn't there to cover the costs of actually providing the care (and then some), it won't work. The only way we're going to be able to afford healthcare in the future is to ration it, somehow. That's the stark reality.

One good way to draw attention to the situation with Medicare would be to take away the private insurance that our Washington legislators enjoy, and put 'em all on Medicare. They'd get an education in a hurry.

 

[erichaj]

I have a different perspective on this. I think the fact that there are non-physician clinicians providing care traditionally provided by physicians is a sign of a doctor shortage. If there were no doctor shortage, there wouldn't be an increasing market for midlevels.

Not ture in my perpective.

I have always said the shortage is really just a maldistribution. More importantly in primary care.

The mid-levels should not even be allowed to practice in that setting. They should only be able to work in a clinic where a doctor is also working.

And to get to the orginal post and kents response. Primary care doctors see much more than coughs and colds, but from a business perspective, if the minuteclinic is taking lets say 20% of the coughs and colds away from your office, you can be in real trouble. A 99213 code does not know the difference between a viral infection or diabeties evaluation. (just an example.).

In the future, primary care docs in larger cities will be focusing on chronic patients and more Ill patients.

If the laws of supply and demand hold here, (which I'm sure they will) couple of things will happen.

1. The demand for faster more convenient service will increase. Thus minuteclinics will prevail.
2. The baby boomers will need more primary care services (A large demand for chronic care service).

The end result is that if primary care doctors want to succeed they will have to be able and willing to manage more chronic patients.

However, medicare is cutting payments.

Merritt Hawkins most recent report was that although the demand is going higher for Primary care, the salaries are not going up.

So, if I were a medical student about to choose a specialty, I would think hard and long about primary care before I chose it.

People will argue with me that money is not the most important factor. I would say you are right. Lifestyle has much to do with it. However, the direction that primary care is taking will significantly reduce the lifestyle benefits that primary care now offers. So, if money and lifestyle are not very good, then the incentive to go into primary care will be gone for the most part. Unless you like to do chronic care.

So, minuteclinic will cause harm to your bottomline.

The president of the AAFP made a very naive statement about these new clinics. He said something like he did not think they would affect Family medicine docs and felt they would actually help them. It was a very politically correct statement.

This tell us just how clueless these people really are.

 

[deleted87716]

The president of the AAFP made a very naive statement about these new clinics. He said something like he did not think they would affect Family medicine docs and felt they would actually help them. It was a very politically correct statement.

Well, for what it's worth, I'm not worried about them, either. Any doctor who feels threatened by these clinics needs to take a long, hard look at how they're practicing medicine in the first place, IMO.

Shoot, I just had a Patient First open up right across the street from me. I'm not worried about that, either. We're doing something completely different, and our patients like what we do as much as MinuteClinic or Patient First's patients like what they do. Freedom of choice, man...it's the American way.

And yes, there are many situations (after hours and on holidays, for example) when having an urgent care center nearby is convenient. I've used them myself.

 

[erichaj]

Well, for what it's worth, I'm not worried about them, either. Any doctor who feels threatened by these clinics needs to take a long, hard look at how they're practicing medicine in the first place, IMO.

Shoot, I just had a Patient First open up right across the street from me. I'm not worried about that, either. We're doing something completely different, and our patients like what we do as much as MinuteClinic or Patient First's patients like what they do. Freedom of choice, man...it's the American way.

And yes, there are many situations (after hours and on holidays, for example) when having an urgent care center nearby is convenient. I've used them myself.

You see coughs and colds right? They do too, right?

So if one of your patients had a choice to see them and not have to wait they could go there, right?

So what if 20% of them did that in a year?

Freedom of choice. No problem with that.

 

[RuralMedicine]

Well, for what it's worth, I'm not worried about them, either. Any doctor who feels threatened by these clinics needs to take a long, hard look at how they're practicing medicine in the first place, IMO.

Shoot, I just had a Patient First open up right across the street from me. I'm not worried about that, either. We're doing something completely different, and our patients like what we do as much as MinuteClinic or Patient First's patients like what they do. Freedom of choice, man...it's the American way.

And yes, there are many situations (after hours and on holidays, for example) when having an urgent care center nearby is convenient. I've used them myself.

In one sense I agree with you...I'm not threatened with losing patients to urgent visit clinics. We have a few in our county one is even within walking distance of my office. Patients who want to be in and out (although I've heard not quite so in and out from patients) in ten minutes will probably not be happy with our same day urgent visit slot policy (which guaratees we will see you if you need to be seen that day but you should understand you may wait because if we have already filled our urgent slots by the time you call we will start double/triple slotting into the last slot of the day). That's ok we all have our limits of what we can do and I can't magically create time that doesn't exist.

In another sense I have real concerns with midlevel providers practicing without adequate supervision which is a significant concern in the urgent visit clinics in our county. This isn't a slam at midlevels, in fact I've considered hiring a PA (and I would have to if I made the transition to RHC or FQHC for my office as federal regulations require that 50% of care be provided by midlevel providers). However, I would not feel comfortable having my midlevel providers practicing where I am not physically present and we would have a well understood agreement of what patients I had to at least eyeball before they could leave etc. I think midlevels can be used to improve access in areas of physician maldistribution but only with adequate physician supervision. My concern is not that my patients will prefer the UVC but that their problems will not be appropriately managed because at least in our community I've had to pick up the pieces of that mismanagement. If there is adequate supervision then I don't have a problem with this.

 

[deleted87716]

You see coughs and colds right? They do too, right?

So what if 20% of them did that in a year?

Who cares? As long as my schedule is full every day, that's all that really matters from a financial standpoint.

A typical URI in a young, healthy person would be coded as a 99213. I'd rather see a 99214 in the same appointment slot, as it's a better use of my time. It's also a helluva lot more interesting.

Most of the runny noses who go to urgent care don't really need to see a doctor, anyway. I've done a pretty good job educating my patients over the past five years to the point where most of them know not to make an appointment until they've been sick and not improving for at least a week.

 

[deleted87716]

Patients who want to be in and out (although I've heard not quite so in and out from patients) in ten minutes will probably not be happy with our same day urgent visit slot policy

Your work-in policy sounds pretty much like mine.

I've also heard that some of these "quickie" clinics aren't all that quick, or even all that cheap. IMO, you're going to get what you pay for.

I have real concerns with midlevel providers practicing without adequate supervision

Don't even get erichaj started.

My concern is not that my patients will prefer the UVC but that their problems will not be appropriately managed because at least in our community I've had to pick up the pieces of that mismanagement.

Happens all the time. As the saying goes: Fast, cheap, good...pick any two.

 

[RuralMedicine]

Kent did you significantly alter this after posting it? I looked at and skimmed through it and didn't have time to comment but it looks significantly different (and better ) than I recall.

Since we're on the subject, I'll share my thoughts on our "broken" system.

One of the biggest problems, IMO, is the fact that our current system insulates patients from the true costs of their care, and places a "middleman" (the insurance company or government) between doctor and patient. Secondarily, there is generally no financial incentive for patients to lead healthier lives, aside from the potential cost of medications, etc. to eventually treat illnesses of neglect. IMO, the current move towards "pay for performance" is misguided, as it incents the wrong people. Paying doctors based on the health of their patients is as backwards as direct-to-consumer drug advertising. Ultimately, these schemes serve the needs of their architects (insurance companies pay less for care, and pharmaceutical companies sell more drugs) at everyone else's expense.

-Actually there is a disincentive if you do not cover well care at all (the norm for most of the commercial plans we have here). It's hard to pay full price out of pocket to have a well child visit every 2months so perhaps you skip that.
-Pay for performance may have started from a legitimate idea but the monster has been created. I have a colleague who is in the process of firing/writing all diabetic patients with a HgbA1C > 7.5 a warning letter they then get their blood work redone in 6 weeks (which I think is a little off since this reflects control over 3months so it would make more sense to intervene, follow blood sugars to ensure your intervention is working and then repeat HgbA1C in 3months but I digress). If they are still >7.5 then he sends them a termination letter and they have one month to find a new doctor and transfer records. This is probably the smart approach from a financial standpoint as we enter an era of PFP but it's not how I want to practice medicine. Interestingly some of his fired patients are incredibly adherent to his prescribed regimen it just isn't working for them/him. Also some of the CMS guidelines for inpatient medicine are not as grounded in EBM as they should be and are actually creating their own problems (as we both discussed on the EM thread)

My wife's health insurance gives her a discount for maintaining certain health parameters within normal limits (weight, body fat, exercise tolerance, BP, cholesterol, etc.) She gets an annual "insurance physical" (basically vital signs, lab work, and a ride on a stationary bike) in order to continue to qualify for the discount. AFAIK, smokers aren't even eligible for the discount in the first place. If any of the measured parameters exceed the limits, she'd be put on "probation" for a few months and would lose her discount if she didn't get things back in line pronto. Personally, I think this is an interesting concept, and deserves more exposure.

I like this (it would probably work with health care savings accounts/ catastrophic coverage plans as well).

I also think health insurance policies should be more like life insurance policies, in that you would purchase them when you're young and healthy, and they'd be portable between jobs. Employers could still provide "health benefits" by giving employees an allowance towards coverage, much like an automobile allowance. I have a hard time believing that insurance companies couldn't market products like that. They just don't have any incentive to do so, as it's easier to negotiate bulk contracts with large employers than it is to sell to individuals.

Again this sounds somewhat like healthcare savings accounts. I'm not sure they are such a bad thing.

Paperwork needs to be simplified, as well. A significant percentage of overhead in any medical practice goes towards billing and collecting money from insurance companies. It's absolutely nuts, when you get right down to it, and needlessly increases the cost of providing care. Many practices are shifting some of this burden to patients (e.g., not filing secondary insurance), and with the move towards health savings accounts and such, I think this is going to become more commonplace in the future. Many practices are also charging for certain types of uncompensated work, like form completion, and I expect this to become more routine. Patients generally act as if we're on retainer already, even though most of us are not compensated in that fashion. It might make sense in the future for this relationship to be made "official" (even if the "retainer" or "administrative fee" was fairly minimal.) A small ($2-5/month per patient) administrative fee could add a significant amount to a struggling practice's bottom line.

I think for this to be successful we'd have to break down some of the middlemen. I actually had a patient who was under the impression that she was doing me a favor by letting me order her mammogram (she thought I'd be compensated in some way and she was helping out). I did order her mammogram because it's the standard of care (note how I worded that let's not get started on the utility/disutility of screening mammograms). On another note my billing person is under the impression that you can actually be compensated for form completion (she's going to provide it to me in writing before she starts just tacking on an extra 20 bucks to all claims--I think she's wrong but if she figures it out I'll let you know). I'm not entirely sure that reverting to a fee for service system with safeguards isn't the way to go. Also I think some physicians would go back to doing charity work and more charity work if they could better cross subsidize. We're moving in the direction of fee for service in some sectors already anyway.

I'm not in favor of a single-payor system. However, I do think that the government could sponsor some form of "bare bones" coverage that would allow every American to receive certain basic services. Private insurance could be purchased to upgrade coverage, if desired. Obviously, the same reimbursement issues that we currently face with Medicare and Medicaid would apply to any form of government-sponsored coverage. If the money isn't there to cover the costs of actually providing the care (and then some), it won't work. The only way we're going to be able to afford healthcare in the future is to ration it, somehow. That's the stark reality.

One good way to draw attention to the situation with Medicare would be to take away the private insurance that our Washington legislators enjoy, and put 'em all on Medicare. They'd get an education in a hurry.

Or just make them use Medicare part D.

 

[erichaj]

I hope your as busy as you want to be kent.

but, keep an an eye on those quick mart clinics.

Whats that old saying:

keep your enemies closer than your friends. (or something like that).

 

[deleted87716]

Whats that old saying:

keep your enemies closer than your friends. (or something like that).

It goes, "Keep your friends close, but your enemies closer." I think it's originally from Sun Tzu, but it was made famous in The Godfather.

Good advice, by the way.

 

[deleted87716]

Kent did you significantly alter this after posting it? I looked at and skimmed through it and didn't have time to comment but it looks significantly different (and better ) than I recall.

I added to it a bit before I went to bed last night.

I have a colleague who is in the process of firing/writing all diabetic patients with a HgbA1C > 7.5 a warning letter

Well, that's the big concern about pay for performance...that it could compromise patient care by encouraging doctors to dismiss patients who jeopardized their bonus, non-compliant or not. Like you, I'd have a hard time with that.

my billing person is under the impression that you can actually be compensated for form completion

I don't know of any insurance plan that reimburses for form completion. You can charge patients directly, as we do. You have to be careful what forms you charge for, however. You can't charge for prescription refills, referrals, prior authorizations, or any other necessary paperwork that's part of your contract with the patient's insurance provider. You can, however, charge for things like school physical forms, nursing home admission paperwork, life insurance and long-term care applications, commercial driver's license physical forms, "get me out of jury duty" letters, etc. We charge $10 for simple forms, and $25 for complex forms (usually those >2 pages and/or requiring chart review). Patients must pay, in full, at the time they pick up their form. We waive the fee in many cases, depending on the circumstances.*

I think some physicians would go back to doing charity work and more charity work if they could better cross subsidize.

No doubt about that.

*Edit: More info on charging for form completion and other unreimbursed services:
http://www.aafp.org/fpm/20040700/43shou.html
http://www.aafp.org/online/etc/medi....File.tmp/template-pt-fees-for-admin-svcs.doc

 

[Faebinder]

In the future, many specialties will find themselves being forced to prove why the medical school model is necessary and better than the mid-level model. Why do I claim that? Because mid levels with these clinics, as ruralmedicine claimed, will spread like wildfire without proper supervision and seek to be independant.

 

[iatrosB]

In the future, many specialties will find themselves being forced to prove why the medical school model is necessary and better than the mid-level model. Why do I claim that? Because mid levels with these clinics, as ruralmedicine claimed, will spread like wildfire without proper supervision and seek to be independant.

Man, there's so much doom and gloom around here lately! Kent, ruralmed, and any other practicing physicians should fly in and reassure us scared med students that primary care (in particular, FM) is not going to go away. Crap like this makes me (and others I assume), not want to do FM (not because I don't like the work mind you, but because "everyone" thinks the mid levels will replace me anyway). I tempted to pursue a sub-specialty that I am only remotely interested in so I will be employable.

 

[deleted87716]

Man, there's so much doom and gloom around here lately! Kent, ruralmed, and any other practicing physicians should fly in and reassure us scared med students that primary care (in particular, FM) is not going to go away. Crap like this makes me (and others I assume), not want to do FM (not because I don't like the work mind you, but because "everyone" thinks the mid levels will replace me anyway). I tempted to pursue a sub-specialty that I am only remotely interested in so I will be employable.

 

[deleted6669]

I think the role of docs in fm in the next 20 yrs will be a satisfying one. they will become "masters of the ship" and while continuing to see pts(those felt to be "more difficult" by the midlevels) they will also oversee a wide array of pa and np midlevel staffers, taking a piece of the pie for each pt they are consulted on. if anything, md's in fm stand to make more money in this leadership role, not less.
in my role as an em pa, the docs I work with get 50% of the production bonus for each pt I see whether they just sign the chart or are more directly involved in the pts care as needed or requested. the avg midlevel probably generates at least 3+ times their expense. I know as a fact having seen the numbers that the docs I work with clear over 1000 dollars profit above and beyond my cost for every shift I work.

 

[Faebinder]

I think the role of docs in fm in the next 20 yrs will be a satisfying one. they will become "masters of the ship" and while continuing to see pts(those felt to be "more difficult" by the midlevels) they will also oversee a wide array of pa and np midlevel staffers, taking a piece of the pie for each pt they are consulted on. if anything, md's in fm stand to make more money in this leadership role, not less.
in my role as an em pa, the docs I work with get 50% of the production bonus for each pt I see whether they just sign the chart or are more directly involved in the pts care as needed or requested. the avg midlevel probably generates at least 3+ times their expense. I know as a fact having seen the numbers that the docs I work with clear over 1000 dollars profit above and beyond my cost for every shift I work.

That perspective may apply to the ER specialty but we are considering primary care... And the reason I state this is that PA/NPs are not going to open their ER independant of MD/DO where as we already see many in primary care doing so...

Anyway... a bit of gloominess is healthy.

 

[deleted87716]

I think the role of docs in fm in the next 20 yrs will be a satisfying one.

"To maintain the dynamism of our specialty, we must define ourselves by what we can do better than everyone else, not by what everyone else is doing."

Source: http://www.aafp.org/fpm/20060400/17rein.html

 

[RuralMedicine]

Man, there's so much doom and gloom around here lately! Kent, ruralmed, and any other practicing physicians should fly in and reassure us scared med students that primary care (in particular, FM) is not going to go away. Crap like this makes me (and others I assume), not want to do FM (not because I don't like the work mind you, but because "everyone" thinks the mid levels will replace me anyway). I tempted to pursue a sub-specialty that I am only remotely interested in so I will be employable.

I wouldn't discourage a medical student from pursuing primary care because I do think that we need a much stronger primary care infrastructure and obviously this will not happen if we are lacking critical mass of providers. From a personal standpoint there are definitely things to enjoy, but it can be hard and I think in general as medicine turns more into a customer service business there is a resultant decline in overall quality and physician satisfaction. Not everything that everyone wants is always in their best interest, safe, or even legal. I think you need to have thick skin to be in medicine in general and perhaps even thicker skin in primary care.

As far as the midlevel replacement theory, I think it definitely will happen in some situations. It is somewhat lucrative to have 6 midlevels running their own little clinic and pay some physician to swoop in and sign a few charts. I can think of a clinic in our county that does just that (and technically this is somewhat illegal as they use a PA/NP mix and what they are doing is probably technically legal--but outside of the intended scope of practice of their NPs it doesn't meet our state supervisory guidelines for PAs). They have gone through a string of physicians in the short time that I have lived here (one left for undisclosed reasons, there were rumors of substance abuse issues but from the few conversations I had with this individual I wonder if it perhaps was that they realized that this was just a really bad idea and got out, another lost their license for unrelated to the clinic reasons, another "quit" but I believe is now coming in once a month to sign their charts, supposedly they are looking for a physician who will be a little more available but are having trouble finding someone). Personally I don't think this is good medicine and I think a physician who agrees to this arrangement is pretty unethical and also not very intelligent because ultimately if something happens it will come back to haunt them rather than the midlevel provider. If you are supervising only retrospectively it's hard to evoke changes in real time.

On the other hand if there is a void in primary care it will impact upon sub specialty care. The subspecialists I "share" patients with look to me to not just provide their referrals but also do a lot of followup care (more relevant in a rural area--as it's pretty impractical to be driving an hour every week to see a subspecialist to follow up something that your PCP can also it allows time for the subspecialist to see the new referrals that the PCP sends). When there is mutual respect and good information sharing PCP coordination is much better for the patient. I have one nephrologist who calls me before he does anything (and I also keep him apprised of changes I make) to make sure that his plan won't "save the kidneys but ruin something else". I also found it amusing when one of my pediatric patients brought their sports physical form to their cardiologist (they had a scheduled visit and mom was thinking ahead and wanted to make sure that they wouldn't need further cardiac workup to play soccer) who filled out the cardiac section of the physical part of the form. At the bottom of the form the cardiologist writes "cardiac clearance for soccer however, must see pediatrician for full exam and real clearance prior to starting practice or competitions. Often when you subspecialize you have to let go of some of your breadth of experience in exchange for your depth and this pediatric cardiologist (who I think is really good in many ways) did not feel comfortable doing a targeted musculoskeletal exam for a sports physical. It's ok because I'm not comfortable with device closures of ASDs in the cath lab.

 

[deleted87716]

I think a physician who agrees to this arrangement is pretty unethical and also not very intelligent because ultimately if something happens it will come back to haunt them rather than the midlevel provider.

Darwinism at its finest, if you ask me.

if there is a void in primary care it will impact upon sub specialty care. The subspecialists I "share" patients with look to me to not just provide their referrals but also do a lot of followup care

That's the thing that people who say "primary care is doomed" continually overlook, like missing the forest for the trees.

I also found it amusing when one of my pediatric patients brought their sports physical form to their cardiologist...who filled out the cardiac section of the physical part of the form. At the bottom of the form the cardiologist writes "cardiac clearance for soccer however, must see pediatrician for full exam and real clearance prior to starting practice or competitions.

That made me smile. At least he was being honest.

 

[RuralMedicine]

That made me smile. At least he was being honest.

Yes, and honesty is always ok. This cardiologist actually referred this family to me as they were seeing someone else and apparently weren't connecting in a way that the mother was happy with so I guess referral goes both ways at times. We also have one pediatric hematologist/oncologist who routinely calls me when she needs to "plug kids back into their medical home" (her words--a little too buzz wordy for me personally). Ok back to patient care

 

[deleted87716]

This cardiologist actually referred this family to me as they were seeing someone else and apparently weren't connecting in a way that the mother was happy with so I guess referral goes both ways at times.

Oh, absolutely. It's not at all unusual for patients to be referred to us by specialists when there's an obvious need for someone to "take command of the ship," to paraphrase somebody else's recent analogy. Like the cardiologist in your earlier example, most specialists prefer to stick to what they know. I try to maintain cordial relations with my specialty colleagues in order to foster this sort of two-way traffic. Word of mouth is always the best way to attract new patients.