White Coat Underground

Early in the prolonged economic crisis a patient who had lost his factory job came to see me. He no longer had insurance, but he had plenty of health problems. Our office normally doesn’t see uninsured patients (we simply can’t afford to) but from time to time we make exceptions. I changed his prescriptions to the cheapest possible effective medications and gave him an online resource for the meds that did not have inexpensive alternatives. I referred him to a clinic that has the resources to care for the uninsured and that may be able to help him get his diabetic supplies.

By doing this, I shifted the cost of this man’s care from my small office to a larger entity. But the money for his care still must come from somewhere. It’s possible that his new clinic may get “disproportionate share (DISH)” dollars from the federal government if they care for many uninsured patients, but it’s also likely that the clinic will never completely recoup the cost of his care.

The uninsured are an unnecessary burden on our health care system. Treating someone without insurance is the most expensive way to provide care. Rather than having the cost and risk of their care pooled with others, the cost falls directly on the patient, who cannot afford it, and is taken on by hospitals and clinics struggling to stay open. Doctors’ fees are only a small part of this burden.

One of the tactics being taken by the anti-health care reform movement is to hype the doctor shortage. Doctors have been kvetching about our health care system forever. When HMOs rose in popularity in the late part of the 20th century, doctors found the increased paperwork, patient loads, and capitated reimbursement unconscionable. And so did patients. HMOs have changed dramatically since then partly in response to these forces. One glaring fact in health care is that it is difficult to make extraordinary profits while maintaining a significant level of customer satisfaction. Health care is about people’s lives. It is not just another commodity.

But HMOs didn’t kill medicine, and neither will the health care bill likely to pass tonight. Primary care medicine is not a lucrative profession and most primary care docs are in it for the right reasons. That doesn’t mean we won’t quit if practice becomes overly burdensome, but the thought of PCPs quitting en masse is laughable. But we are already having trouble creating enough PCPs. About four percent of American medical graduates choose primary care. One of the reasons for this is the enormous debt they incur during their education: close to 200K average. Primary care medicine simply doesn’t pay well enough to manage the debt well. And primary care is becoming more important as we learn more about medicine. We have measures of effective care now that should be tracked, such as how often a diabetic receives foot and eye care. Private insurers have discovered this, and want the data to help reduce costs: prevent progression of diabetes-related diseases, and profit goes up. Private insurers have started giving “bonuses” for this data, which in effect means withholding money to doctors unless they get the data. Collecting and reporting this data, without a unique, national database, is a huge burden.

If health care reform passes, it’s unlikely that this would change. This is coming one way or another—it’s good for our health, and we physicians will have to find a way to adjust, as we always have. But we’ll need some rational actions to help us. Creating a national database, one that is compatible with our own electronic health records; creating interoperability between EHRs; and providing the resources to help physicians track this data is something that cannot be done on the level of individual practices.

Our health care “system” is being hobbled by millions of uninsured and lack of any support for prevention. If health care reform fixes only the first problem, that’s a start. I love having full exam rooms a crowded waiting room. Hopefully, we will keep an eye on part two, and make it possible for people to choose to practice primary care, and to do so effectively.

Comments

#1 Arnold T Pants
March 21, 2010

The debt load is a huge problem- if you go to a private school (as I do) it is nothing short of panic inducing. It really influences the decision making. I intend to apply for a pediatrics residency and going into primary care is very unlikely to be an option for me, as pediatricians get paid much less across the board, primary care and sub-specialties alike. We enter medical school with high ideals, but the financial reality is inescapable.
#2 CanadianChick
March 21, 2010

we have a shortage of PCP/GPs here in Canada too, especially in more remote areas – actually we have a shortage of every type of doctor in remote areas (90% of our population lives within 100 km of the US border).

Given that we have both universal health care AND public universities, I’ve never quite understood why we don’t offer student loan remission (at least partial) as an incentive to either go into family practice or to remote areas. The benefits would surely outweigh the costs, even to a politician…
#3 Autistic Lurker
March 21, 2010

Canadian Chick, there’s many problems creating a shortage of doctors here such as the cost of training them and also, the number of immigrants who have MD from countries such as France where’s there limited parity. In the province of QC, doctors can go to practice in France without condition but the inverse involve some bureaucracy and maybe some more training too; that’s from my previous workplace where I met 2 MDs with their education done in France.
#4 The Blind Watchmaker
March 21, 2010

There is a definite shift in the way primary care will be practiced. The new “Patient Centered Medical Home” model is the new buzzword for primary care. Under this model, individual patients will become more of a community of patients with shared problems. There will be group visits to cover common problems. A practice’s income will be tied to how the practice manages common medical problems as a whole within the practice’s patient population, rather than on a patient by patient basis.

This sounds rather impersonal, and I guess it is on some levels. However, as Mark Crislip, MD has pointed out on Quackcast numerous times, in long term studies, better outcomes in disease management are achieved if patients (and problems) are treated uniformly. The variables are then able to be tracked and practice adjusted accordingly. In order for it to really work, though, patients must have the freedom to choose the doctor. They are still the consumer. This will discourage complacency among doctors.

The change will be long and laborious. I, like many, naturally want to resist change. It is easier in the short run to stay the same. But change is already here and will occur with or without government legislation. The legislation will provide a larger patient base that we are able to treat. Like it or not, a change in strategy is needed. I hope the new model will work. If so, we will all be better off.

Health care is a business that must adapt to change. Unfortunately, evolution requires a dying off of those who cannot (or refuse to) adapt.
#5 Despard
March 21, 2010

Canadian Chick – I live in Canada too, and have friends who are just starting their residency, who want to be family doctors. You actually do get a large lump sum as a bonus for starting work in a remote area. Currently it’s $75,000 for Kingston and $100,000 for Belleville – neither of which are hugely remote, so the really remote areas must pay more.
#6 Pascale
March 21, 2010

Re #1: I am a pediatric subspecialist, a nephrologist. I could have made a lot more initially going into primary care pediatrics than I did as an academic subspecialist. Only now, with a named professorship, have I surpassed what my colleagues from residency make.
#7 Silver
March 21, 2010

Pal, I work at a CHC. You’re right – we don’t recoup the cost. We get funds to offset those costs, but, since we see a disproportionate number of uninsured, homeless, and Medicare patients, we basically just bleed out the money. In other words, you’re all paying for it. You’re paying for it in taxes and higher premiums. I’m personally paying for it (where I live) by working for less than half of what I make in private practice and pulling a lot of 14h days on a 8h salary day, because I think it’s interesting work and I find it stimulating and I’m never, ever bored. And I work with lovely people.

Other than being able to connect a patient to a low-cost/no-cost diabetes educator and possibly 340b pharmacy pricing, CHCs usually can’t get other supplies, etc., at no or especially low cost. The 340b pricing can be significant for certain drugs, but doesn’t make much difference on DM supplies. I’m not sure if your state provides money for case-management services to help a patient track those supplies down or not. Most states do not reimburse for or grant-fund for case management at this point, with the exception of patients who are receiving HIV/Ryan White funding, perinatal patients, some homeless case management funding, and patients who are seen at community mental health centers.

Note that the CHCs do, however, participate (many of them) in the health disparities collaboratives. These are aimed at long-term management and tracking of chronic disease outcomes (I’m familiar with the ones tracking DM, hypertension, and depressive disorders); they aim to prevent complications. They do correspond and collaborate nationally via online and phone meetings, go to national conferences, etc., to standardize care. They pool data among ALL the CHCs. It would be ideal to extend these to FP offices. CHCs are clinically in the place of desperation in which we have to do this, which is why I suspect the projects were funded in the first place. I’ve never looked up the cost outcomes data. (See reference to 14h days above.)
If our patients were coming in earlier, we’d be more prevention oriented, and I think the CHC peds do something along these lines – I’ll have to ask. Alas, most of our patients haven’t had good (or any) access for years, and so they’re coming in at the point where we’re trying to prevent stroke, not reduce mildly elevated BP.

Our CHC loses about $40 on every Medicare patient we see. That’s not the discrepancy between our billed cost and collections – that’s our actual cost v. collections. Since we’re the only GP clinic in our region taking new Medicare patients, and since we are not going to stop doing so, we’re about to implode. Add to this that our fastest-growing Medicare population is young-disabled Medicare – usually diagnoses relating to mental illness or chronic painful conditions – and these are NOT simple patients to manage.* Medicaid – we do OK on Medicaid. Private insurance and self-pay is fine for us. Sliding fee scale (SFS) patients are actually fine for us. Our actual collection rate is quite good.

Incidentally, we operate under the same SFS restrictions as anyone else can, if anyone is wondering. There is a popular misconception that one can’t slide fees, as it violates the contracts with third party payers as to ‘lowest rate.’ There is, in fact, a sliding fee scale exemption, if there is a written SFS on file and a written and outlined policy, etc. – interested readers should check contracts. Once the usual cost of the bill-out is deducted from the visit and then assuming 100% collections – which is appropriate – it looks not that bad, when compared to the usual denial/non-collection rate.

I am always amused by patients who come in saying, “I -have- to come here” (to the Poor People’s Clinic) and then are quite pleased and delighted. Many to most of them stay with us even once they get their insurance back. They appreciate that we were there. We’re usually running late, because, well, we see complex, sick patients, and these visits take time… not getting medical care for 15-20 years tends to add up to some problems, and, of course, then we have the issues re: Medicare patients, who tend not to be 25 year old volleyball stars. And we have people at least three days a week who walk in and are so sick that they are direct admits. Most of our patients understand that the next emergency may be theirs.

Increasing funds for CHCs in this bill is great, it’s spiffy, etc. It’s nice to have somewhere that everyone can refer their financially inconvenienced patients to. (And we plan to keep them for the long term. We are a medical home, we are not a medical shelter.)
But it’s not going to do much good if 1) we don’t have GPs (and other specialties – psychiatry, FP with OB, and some specialty consults from endocrinology, ID, and nephrology…) to staff them; 2) Medicare continues to suck money from ‘cognitive medicine’; 3) there isn’t some case management support to retain the FPs, etc., if we can get them and then pay them.
I won’t even get started on the nonsense that is a PERM audit and sampling techniques, nor on the evils of the new RAC system, other than to say we are spending at least as much on ‘compliance’ with documentation regulations as we would be on a full FP (if we could hire one.) And NO ONE at this clinic is trying to scam to get rich. Hahahahaha. We’re trying to finish seeing patients by the end of the lunch hour.

There’s increased funding for CHCs in the bill as it sits but there’s a time lag. We’ve had a major spike in referrals from the community, not to mention self-referred patients, and we are 5 weeks out for new patients as it is – and we’re now short staffed. Your community clinic is probably in a better situation, as we have some unique stressors.

And that little rant just ‘outed’ me to anyone who’s reading and knows me and has been around me after about 75mL of single malt, so, uh, hi out there, guys.

‘K, sorry bout the length of that rant. I have some CHC issues.

PS:
*Re: the fastest-growing group (in my area) being young-disabled Medicare. I’ll be curious to see if that changes with health-insurance reform. (Sorry, I’m not calling it health care reform at this point.) Right now, pursuing SSDI or SSI is the only way for people with certain conditions in my state to get access to long-term health care. You literally can not buy medical insurance that will cover psychiatric care as a single-payer policy – only in a group policy, and then it needs to be a group of a certain size. I looked into this for my private practice.
My state’s Medicaid requirements are stringent – within the FPL guidelines, pregnant, parent of a young child, or on disability/in process and very likely to receive. With time constraints.
Therefore, if you have any psychiatric illness, your only shot at getting coverage even for the short term, if you are not employed by a large company (or pregnant, etc.), is to apply for SSI and eventually then, if you get it, end up on Medicare.
I’m interested to see if the SSI application numbers change with insurance reform or not.
#8 Dianne
March 21, 2010

Our CHC loses about $40 on every Medicare patient we see

IIRC, our bureaucrats say that we recoup about 70 cents on the dollar for medicare patients, about 40 cents on medicaid patients and…about zero on self-pay or charity care (a state program to pay for people with no resources but not qualified for medicare or medicaid). More medicare patients, please.
#9 Silver
March 21, 2010

Because of how our state remits, we get cost plus a set margin for Medicaid patients. It’s remitted as a flat rate regardless of cpt, then adjusted somehow.
Self-pay and SFS patients are required to pay at the time of the visit, or make and stick to a payment plan, barring overrides for medical necessity. It works. Even the copay helps keep the lights on.
I’ll have to get the “per dollar” cents lost numbers. I like that.
I think we may see ‘sicker’ Medicare patients. But then I think we may all feel that way? It’s just that I have not seen the mythical “LOL in NAD” for a beta blocker refill at our clinic. Our patient would present a bit demented and maybe encephalopathic, with a lab slip from 9 yrs ago reading + HCV, and it would go downhill from there.
#10 SurgPA
March 21, 2010

Reimbursement issues aside, I haven’t heard much lately about another of Pal’s comments; national health database and widely-integrated EMRs. In his first national speech on health care many months ago, Obama said this was a priority, but it seems to have fallen off the radar. I hope this is addressed in the final bill and simply doesn’t garner media attention as it’s not controversial enough. I work for a multispecialty group, and we operate at a local hospital – soon to be 2 local hospitals. That means I routinely use 3 different medical records, none of which communicates with the others. If a patient is seen at our clinic for consult, maybe was at ER#1 for an acute visit prior to this, and has a subsequent operation at hospital#2, I cannot compile the overall picture without logging into three different systems. Complicate this picture by making the patient medically complex with prior surgeries/treatments in another state, and you can appreciate the difficulty seeing the entire picture of a patient’s health history (and even the “best” patient probably doesn’t know some of the details we may need.) I see support and development of the health-records technology as key to improving our system and its efficiency. I wonder how a national database dovetail/conflict with HIPAA-privacy issues, although my experience is that most patients are frustrated that I don’t have their prior info, rather than because I already know too much…
#11 Vicki
March 22, 2010

We don’t even have good local record-sharing, unfortunately. I was an emergency admit for a gall bladder removal, a couple of years ago. We gave the hospital my primary physician’s name and phone number, as a matter of course.

Nonetheless, the next time I went to see her (after follow-up with the surgeon), I had to tell her that I’d had the gall bladder out. This isn’t just in the same state: her office is less than two miles from that hospital. If they aren’t going to notify my GP, why bother asking for her name and number?
#12 James Sweet
March 22, 2010

Given that we have both universal health care AND public universities, I’ve never quite understood why we don’t offer student loan remission (at least partial) as an incentive to either go into family practice or to remote areas. The benefits would surely outweigh the costs, even to a politician…

This was my first thought too, that it seems like it would not be terribly expensive to partially subsidize the education of PCPs to make the long term cost/benefit more appealing.

widely-integrated EMRs. In his first national speech on health care many months ago, Obama said this was a priority, but it seems to have fallen off the radar.

Well, yeah. Far more important that a two thousand-year-old death cult’s obsession with the morality of reproduction be given a ridiculous amount of undue weight and then ham-handedly foisted on the rest of us, than to address tedious things like logistics.
#13 Beth
March 22, 2010

I live in a smallish city surrounded by a rural area. Some GPs practice in a group of other GPs, but the group shares only the receptionist and the lab. (This being that if your doctor isn’t in, you’re out of luck — no seeing another in the group. And you write your checks to your doctor rather than to the office.) Otherwise, offices generally consist of one doctor (or maybe two) and PAs or ARNPs, often in liberal numbers. I go to one of these offices and have never seen my doctor. That’s how we’re coping with the doctor shortage — common ailments often don’t have a doctor’s involvement.
#14 eNeMeE
March 23, 2010

I’ve never quite understood why we don’t offer student loan remission (at least partial) as an incentive to either go into family practice or to remote areas.

Any healthcare worker gets bonuses for moving to remote locations. I’m only aware of this as my wife recently became an OT, but if you go and stay for a certain length of time you can get student loans forgiven.

…I think. Recently isn’t that recent anymore.
#15 redrabbitslife
March 24, 2010

@CanadianChick- I am a new rural family doc in Canada. Most of the provincial governments provide grants to pay off tuition debt and other loans if you intend to work in an underserviced area- and these can be rural or urban. Additionally, many communities offer funding to help defray some of the costs. There is also a Northern Allowance if you want to get really remote, though frankly, if you’re going that far north, you’re not doing it for the cash.

It can be a bit limiting in the first few years, and in my case it won’t pay off all my debt load (but the current funding models make that fairly straightforward and with prudent cash flow management I can expect to be debt-free in about 4 years, even counting set-up costs).

There’s also funding for EMR development, computers, and continuing medical education.
#16 jennyfromtheblog
May 3, 2010

I am worried about the effect of mandated insurance, of which some of the “affordable” plans will demand high co-pays and high deductibles. I fear that, as I am forced to do now, people will have the wherewithal to buy insurance, but not the means to pay for office visits, prescriptions, co-pays for lab work, and, heaven help them, the deductibles for hospitalization.

I see looming larger and larger numbers of people who will be forced to practice “self-denial of care,” the kind forced by limited budgets. They will meet the demand to “have” insurance, just not the means to use it for their health CARE.

I know I’ve had to do it: I have individual insurance, it kept going up 15 or 17 or 20% a year. I kept changing to higher deductibles, etc. Now I don’t purchase certain prescriptions; I stretch out my appointments for chronic ailments as long as possible; I had to choose to try to find a way to do without recommended PT by reading on the Web and hoping I was doing exercises the correct way; and, now, this year’s mere 15% price increase in insurance means I will have to self-deny myself health insurance. In a month or two. I do need to get my annual whole body scan done for my cancer, however.

Oh, why DID Obama demand Single Payer be taken off the table? PNHP.org gave the answer with Improved Medicare for All.

The intense sadness of lost opportunities….