Say Hello to "Dr.Nurse"

[Spine Specialist]

http://blogs.wsj.com/health/2008/04/02/say-hello-to-dr-nurse/?mod=WSJBlog



Great.

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[Jeff05]

it is quite scary how much nurses DO NOT know or UNDERSTAND about the practice of medicine (making decisions). it would not be that scary if they were not trying so hard to put themselves into a position to make those decisions. the problem is that THEY DO NOT KNOW HOW MUCH THEY DON'T KNOW. no insight. i categorize them in the same group that thinks that anesthesiology is boring and that we do nothing - no idea.

 

[PMR 4 MSK]

I've discussed this several times recently with our nurses (ASC and clinic). None even want to consider training for something like this. Most go into nursing to be a nurse, not to have the responsibilities of a doctor. Those that do go on for this are often frustrated doctor-wannabees.

Let them do it, and when they start getting sued as much as doctors, the malpractice will get them back out. And when insurance companies and Medicare start saying they won't pay for a D.RN, just like they won't pay for PT Asst now, they'll be less pushing for it. In the meanwhile, it's the patients who'll pay for it, financially and medically.

Maybe they'd be good for the Medicaid population - no one else wants to take it...

 

[ampaphb]

Let them do it, and when they start getting sued as much as doctors, the malpractice will get them back out. And when insurance companies and Medicare start saying they won't pay for a D.RN, just like they won't pay for PT Asst now, they'll be less pushing for it. In the meanwhile, it's the patients who'll pay for it, financially and medically.

Maybe they'd be good for the Medicaid population - no one else wants to take it...

The insurance companies will preferentially drive patients to those that cost the least. Letting them do it is like saying let optomitrsits do Laser Eye Surgery, or psychologists prescribe meds. These are ongoing scope of practice issues, and allowing yet another group to gain a foothold is the wrong tactic, IMHO.

The your underlying premise seems to be Medicare won't pay for an under trained paraprofessional to practice Medicine. The Louisiana experience with CRNAs seems to indicate otherwise. And the idea that they can just care for the underserved population? Great in theory, but they use that as a means to gain a foothold, and then come back the following legislative session to say "now we want to practice everywhere, and on everyone, not just on those groups you permitted us to in the past."

 

[Tenesma]

the only way to have an impact is to eliminate access to care --- while this initially would impact volume it would be for the best on the whole...

i know a doctor down the road who stopped taking medicare last year - his volume is down but his income has returned to baseline....

if we collectively did this we would be more highly valued, but instead we keep on doing what we shouldn't be doing -- which is beinding over...

medicare KNOWS that every time they reduce payments, that doctors respond by seeing more patients.... so there is no disincentive for them to keep on reducing payments...

i looked at my numbers - if i dropped out of medicare, my volume would drop by about 30%.... but the 70% will now no longer have to wait 3-4 weeks for appointments, and i can book them right away.... i am thinking hard about it

and so should all of us...

 

[Disciple]

Won't eliminating access to care give the government more reason to utilize mid-levels?

What about the moral issue? Most of my most pleasant/satisfied patients are Medicare. I'm not sure how I'd feel about cutting Medicare altogether. Maybe limiting the number of new Medicare patients, but quitting completely?

 

[Tenesma]

#1 - medical care is not a right (unless it is an emergency according to EMTALA)

#2 - let the voters decide --- retirees are one of the LARGEST voting blocs in the country - and healthcare access is their number ONE issue (along with social security income)

#3 - not all of us can contractually opt out of medicare because a lot of hospital or academic centers force the issue

#4 - so technically, medicare patients will always have access to care

while medicare patients are pleasant and usually satisfied, why is that we (as physicians) are the ONLY ones in the business world to accept such a proposition.

Medicare is projected to cut our reimbursements by 10.5 percent in July and by another 15% in January of 2009... with medicare going into negative cash-flow this year, and depleting their Trust in 2019/2020 - what makes you think this trend will reverse itself...

And just because you drop out of medicare doesn't mean your medicare patients can't come to see you - it just means they will have to pay a reasonable fee for your time and effort...

I am out-of-network with XYZ provider, and over time enough patients have complained to their employers about not being able to see me or being able to afford seeing me because of my non-par status.... so guess what 5 large area employers have done in the last 12 months??? they changed back to an insurance which i am par with so that their employees would quit complaining...

we have to stop this insular mentalilty of physicians because we continue to under cut each other...

of course the government will try to respond by getting more mid-level providers --- but I haven't seen that happen --- in my state there are only 3 pain doctors that take medicaid....
in my state there is only 1 neurology group taking medicaid... I have yet to see the state/medicaid pursue the growth of mid-level providers for sub-specialties.... and if a mid-level provider is content accepting $14 for a 99213 follow-up visit - then fine...

also, if you choose to keep your current medicare population but refuse to accept new medicare patients then you are taking a first step towards more independence...

also - remember that ALL private/commercial insurances base their re-imbursements as a % of medicare reimbursements - so as we continue to fold in front of medicare, we will continue to see the other payers take advantage of us....

why is it that the CEO of United had a salary of $130 million last year with $1.6 billion in exercised stock options (admittedly he had to pay a fine of $600 million) - and we have to accept lower payments... this is a for-profit industry, and we can't be the only ones providing charity care all the time

 

[Disciple]

while medicare patients are pleasant and usually satisfied, why is that we (as physicians) are the ONLY ones in the business world to accept such a proposition.

Medicare is projected to cut our reimbursements by 10.5 percent in July and by another 15% in January of 2009... with medicare going into negative cash-flow this year, and depleting their Trust in 2019/2020 - what makes you think this trend will reverse itself...

I don't think the trend will reverse itself. Taxes on the middle class will go up, and we'll have things like P4P and UR for Medicare.

I don't disagree with any of the ideals you've put forth, but have accepted the fact that for every physician that stops seeing Medicare, there are probably 2 others that would be willing to take up the slack. The government will let midlevels help with the rest.

I know alot of physicians who are fine with $100-200K/year and aren't going to bitch too much unless their salaries start to dip below $100K. This is more a coalition of the willing, and maybe those willing should look for another solution.

 

[Ligament]

Tools for opting out of medicare and insurance altogether:

http://www.aapsonline.org/

A really good organization. There are seminars, webcasts, podcasts, articles on opting out, and reasons to do so.

 

[Tenesma]

how do the doctors survive that are cash only or are very selective about insurance??? well they survive because their income isn't all that badly affected by dropping out of medicare

if there are some schlub's who want to do medicare/medicaid all day, work twice as hard for the same amount of income - then so be it... but patients won't be satisfied with 3 minute visits...

it is always a self-fulfilling prophecy and over time the medicare patients will come back to you because 1) you are good 2) you have good outcomes 3) you spend a lot of time with them 4) you have time to listen - and they will be willing to pay cash for this.... medicare patients can afford a big screen TV without government help, medicaid patients can afford to go the casino every weekend, medicare patients can afford groceries.... and for those on fixed-incomes you can always strike deals with significant discounts...

 

[Mister Mxyzptlk]

The payers in my area are pegged to a % of Medicare and they are ratcheting down to Medicare rates. When the tide goes out on Medicare all of the boats will sink equally in my neck of the woods. So not accepting Medicare isn't the answer for me.

The PCPs will lead this fight. They also get a narrow differential on commercial insurance but for them the old people are a major hassle - long visits for the same money as young healthy people. They are the ones that I see dropping Medicare around here, and I think the politicians are starting to take notice (because AARP is making them take notice).

Gimme the old folks any time. Much easier to manage, more respectful, less demanding, fewer (but not zero) drug issues and for the measly % more the private carriers pay they can shove the pre-cert crap where the sun don't shine.

 

[Tenesma]

gorback --- agreed BUT

1) if less doctors take medicare, and AARP drives politicians nuts - then there is a good chance that medicare will have to raise rates in order to recapture the market

2) if medicare rates go up - then those private carriers will adjust accordingly

3) we are lucky right now that medicare doesn't require pre-certs... it is just a matter of time (i am guessing 2-4 years) before medicare goes the same route of pre-certs for procedures and imaging...

4) plus also remember, medicare is the only contract you sign that has CRIMINAL liability spelled out for any misdeed - even if there was NO intent. If you goof up with Blue Cross, they will just create an off-set and kick you out... BIG difference...

 

[Mister Mxyzptlk]

#1 is already happening.

#2 would work short term, but then they will just decrease the % premium they pay, e.g., drop from 110% to 105%. At least it's not a 10% cut.

I don't know how #3 will pan out. You don't want to get between the older voters and their medical care.

#4 is the Sword of Damocles hanging over our heads. It's like a shakedown visit from Vinny and Guido: "Nice little practice you have here Doc. It'd be a real shame if something happened to it. Now, we think you owe us some money. You can pay what we say or you can fight us. If you pay us we go away. If you fight us and lose then we'll ask for the triple penalty. Even if you win, it will cost you a small fortune and most of your sleep. Think it over. We'll be back tomorrow for your answer."

There would be about $60B freed up if they didn't pay the Medicare Advantage plans a 13% premium over Medicare cost. If you want to dump something, dump MA plans. I refuse to take them.

http://www.aarp.org/makeadifference/politics/articles/making_medicare_fair.html