The Sad Case of the Patient Protection and Affordable Care Act

[DrDemento]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Les: Weather permitting-Jenny and I walk the larger flea markets within driving distance most weekends. It is great exercise and we meet such a great assortment of people. Often we are able to offer some medical advice and refer people for care that they would have otherwise not gotten. We have a blast and i am not under the constant pressure of the office practice. And people are incredibly grateful. But thinking about it all-if I had to start over now-I just do not know if I would have made medicine my career. Of course earning a living is a concern but I always needed to be my own boss. I am not one to take directions from others.

[leswp1]

Re: A system that doesn't want to change

Dr.D I fear you are right. It is also nice to have some one get it. I am cut of the old cloth as well (not to the hat, stockings and whites but the dedication to the patients thing)I am so sick of hearing this is the new normal.

Probably totally illogical but I have very little prob with medicare/aid limiting things- at least they give something and those who get that should be grateful. (something I think people forget) It is the for profit insurance co that feed the general public the hooha about caring for the patient, how it hurts them to cut things, it is all the gov't/ regulations fault while their CEOs make more than the GNP of half the developing conunties that makes me want to puke. The $ is the only motivator and it is amazing people don't realize that.

Sometimes I want to go work at the community ctr but the red tape to change practices takes about 6 months and the thought of having to learn a new system/leave my patients behind stops me..

[RStarr]

Re: A system that doesn't want to change

When your links don't work for standard browsers, people won't bother.

And you're training to become a doctor? We're doomed.

http://www.escapefiremovie.com (screening in Denver tonight. s/o Coach K!)


Don't worry. My goal is to never touch patients. Ever. My work will emphasize the "MBA" portion of the degree. America ruined my dream of being a doctor. One day I'll own all of you (cause you dumb asses are already doomed).

[St. Clown]

Re: A system that doesn't want to change

QFT. And because not one poster watched it. Duh.


And in other news, medical school is some seriously effed up tish as well. this, much like the healthcare dilemma, most will not understand.


I'll gladly go back to my 100K/year, 3 day/week job as a bedside nurse any **** day. carry on.

When your links don't work for standard browsers, people won't bother.

And you're training to become a doctor? We're doomed.

[RStarr]

Re: A system that doesn't want to change

Great film...could be better, yes, but should at least be mandatory.

http://m.youtube.com/watch?v=89nnsWZhkI4
http://m.youtube.com/watch?v=1Sp4Y_DNMYk

QFT. And because not one poster watched it. Duh.


And in other news, medical school is some seriously effed up tish as well. this, much like the healthcare dilemma, most will not understand.


I'll gladly go back to my 100K/year, 3 day/week job as a bedside nurse any **** day. carry on.

[DrDemento]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Les: I saw the handwriting on the wall starting back about 1997. I had a few episodes where i could not practice the best medicine for patients because of interference by HMO's, insurance companies, and Medicare. I discussed this at length with my office manager (my nurse and wife). I told her after 30 years of practice, for the first time, I could no longer practice like i have to. I told her I was going to shut down the office rather than become part of this system. I am no expert on much in this world but when it comes to medicine-I refuse to compromise. I was not going to allow some 21 year old girl on the phone who was popping gum in my ear tell me that i could not biopsy a nuclear physicist sitting in my office because he was not referred to me properly by his gatekeeper. Because I am me-and Jenny is Jenny-We wanted to personally explain to each patient. It took me 3-4 years to tell each patient we saw and notify all the others by mail. I could not close down without making sure each and every patient was either totally stable or referred properly to someone who could care for them as well as possible. it was an incredibly tough decision. Neither Jenny or I had come from families with any resources. Our retirement would have to be funded by what we had saved or invested (and being a doctor i of course knew nothing of finance-doctors are the WORST businessmen even though they would never admit it). We are very fortunate to have planned our life the way we did. We do not have large overhead. We live within our means. And i have made a second career out of investing and have surprised myself with how well i have done.
Do we miss practicing? Gosh, do we ever!. But i continue to do consulting work and i keep current on CME and even do occassional teaching. Jenny is the one who misses practice the most-she is cut from the old school cloth. The old time nurse. White shoes, white uniform, white hat and stockings. I still refer to her as nurse Ratchet. But she lives for the profession and is as devoted to helping people today as ever. We do not consider ourselves anything special, and i am sure most of my generation of physicians feels exactly the same, but we are the medical personnel that has been driven out of the profession and we are losing more like us every day. I salute you for continuing to try to provide the best of care. I am just not sure for how much longer you will be able to do it.

[leswp1]

Re: The Sad Case of the Patient Protection and Affordable Care Act

A friend of mine is a family practice doctor. He was, at one time, practicing in a small clinic with some friends of his. A number of years ago he moved over to join the Mayo Clinic Health System. We were talking one night and he was lamenting the loss of the small practice he had with his friends. I asked him why he had made the move. He said when they started, their practice could get by with about 1.5 administrative staff people per doctor. He said it's easily 4.5-5.5 per doctor now, and was a prime reason why he felt he was "stuck" where he didn't really want to be. I found that sad.

-When I started we had a receptionist/biller, LPN, Dr and me (in my first practice) 25 yrs ago. This was more than enought to cover everything. So it was 2 providers (sorry Doc) and 2 ancillary staff. (We also farmed out transcription but that was optional)
-By the time I left we had 8 providers (3 full time, the rest PT) /8 nurses, 4 billers, 4 receptionists, 2 file clerks, office manager, (and a partiridge in a pear treeeeeee)
-When I came to this practice 10 yrs ago it was the Doc- FT, me PT, a nurse and a receptionsit/biller
-About yr 2 we added one more NP full time and another nurse to make it 3 providers/2 nurses.
-Over the next few yrs we needed to add specialized billing people as the insurance issues were so complex one person could no longer handle it.
-Billing issues eventually became so complex we had to outsource the billing. The billers could not keep up with the billing and keep current with the all the changes. We were losing 10s of thousands of dollars because they could not keep up with the volume of resubmissions.
-We added another nurse and receptionist (both PT) as the volume of patients, calls and need to triage increased.
-Office manager was added next because there were so many administrative issues to deal with credentialing, multiple insurance requests for data/chart review we needed a dedicated person to do it even with out sourced billing.
-we added a telephone tree (HATE THIS!!) because the number of calls exploded from patients needing things and the receptionists could not keep up.
-We now have 3 nurses- all FT, 3 receptionists- all PT, outsourced billing. The Doc now has to take 2 afternoons to do admin work to deal with all the AQC, requirements, various meetings with hosp regarding all the initiatives the PHO gets us into that affect our reimbursement, etc. All ancilary staff work on the numerous requests for data from the insurance co. at least one afternoon a week.
-when I started the amount of admin work was negligible. The Dr is doing about 50/50. I am about 1/3 admin, 2/3 pt care with documentation taking as much time as the actual patient care.

As primary we are the 'gateway (unpaid of course) that is supposed to get our patients to comply with seeing us rather than self referring to where ever else they decide to go. We already are required to call every patient that goes to the ED/minute clinic/ doc in the box to follow up on their visit and determine whether there was true need. If there wasn't we are supposed to chastise them. We have to send documentation for every one of these visits regarding our determination to the PHO.

As of this AM (I thought of this thread immediately) we had a meeting and there is serious thought to adding someone who does nothing but track the initiatives for the various insurance companies/medicare. The PHO now has signed on to a Medicare initiative to track all Medicare patient billables for redundancy/ overuse of specialists, etc. to cut the costs. (I understand the motivation to decrease redundancy but I don't have time for this BS). This will not change our renumeration but we are supposed to document a discussion with every Medicare patient every year regarding the PHO participation (and ours by default) and give them the option of declining to participate in this initiative. The PHO of course sent out the packets to all Medicare pts but have no standardized processes regarding what we are supposed to do other than who is the gateway and responsible for the education of the patients (um, yup- us).... guess who gets no renumeration but much chastisement if people are not changing their behaviors..... guess who is supposed to find the time to do this..... The I saw 3 people that needed to have this 'discussion' today- wasted about 30 minutes of my time to explain stuff that we do without being required to do it but now, because we need to prove to the PHO we did it I have to formally document the BS- where no one knows- not in the chart, there is no form. Maybe on my left cheek??!!

Les: I wish we had a simple solution but since the government has been so involved in determining what is the best way to provide medical care for the population for the last 50+ years, there is no quick fix. They have had enough time to screw things up royally. They use all sorts of worthless statistics to pass rules and regulations that simply make the system more cumbersome, more chances for fraud and abuse (by providers and patients alike), and unwieldy. If anyone out there right now thinks that they are getting the best and most attentive medical care please raise your hand. In the government's attempt to contain medical costs they have just introduced more and more types of providers (whether scientifically proven and valid or not) into the equation to take a slice of the medical money pie. In another post I asked the query-is medical care a right? Is food a right? Is housing a right? With the follow up-then is everyone entitled to the same medical care, food and housing? If not-are we entitled to a minimum standard of food, housing and medical care? And who defines what that minimum is? These are basic questions that need to be addressed before we can make any valid attempt to manage the cost of medical care. Obviously i do not know the answers. I simply know from numerous personal anecdotal examples i could give-that I have been restricted from giving the best medical care and the best advice and medications by people who have never set foot in a medical school or even treated a patient. We seem to be on the same page-but with a slightly different perspective. I am no longer as active in the practice but i still do consultaion work-totally gratis. I have not charged for medical care or advice in 11 years. I sometimes wish i could just sit back and relax and do nothing-but i love what i do far too much and the feeling of providing help for someone was the absolute number 1 reason I went into the field.

Thank you. I so envy you. As I listened in the meeting today to the Doc trying to sell why all the BS would be worth it I just wanted to go to work at McDonalds. I found it so sad that she buys into all the BS of being compliant with all the stat gathering as a help to patients. How is it ehelpful that I spend less time with my patient than I do making sure all the stuff is documented/billed with crazy codes to 'capture' what I did? It is so bad I would almost pay to work gratis.

[FlagDUDE08]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Are you an actuary?

it seems like every time I ask an actuary - any actuary - a question, they always tell me how to calculate the answer on my own.

Do you typically pay the actuary first?

To answer your question, though, I am not an actuary.

[DrDemento]

Re: The Sad Case of the Patient Protection and Affordable Care Act

I believe all you would have to do is read a bill that has been passed that contains the government budget. I'm sure FOIA would allow you specifics.

Years ago I received some piece of paper from the AMA with some numbers on it but I trust them as far as i can throw them. I also remember something from my American Board but it was far too long ago to be relevant. It is not an easy number to come by-I have searched all over the web. I can find all sorts of gross numbers that show what the total expense may be in any given year-but it is never broken down as to % paid to physicians, % paid to administration, etc. So much of what is spent is just not carefully accounted for.

[joecct]

Re: The Sad Case of the Patient Protection and Affordable Care Act

I believe all you would have to do is read a bill that has been passed that contains the government budget. I'm sure FOIA would allow you specifics.

No government budget has been passed in the last few years. The Appropriation Bills can be found here: http://thomas.loc.gov/home/approp/app13.html

[FreshFish]

Re: The Sad Case of the Patient Protection and Affordable Care Act

I believe all you would have to do is read a bill that has been passed that contains the government budget. I'm sure FOIA would allow you specifics.

Are you an actuary?

it seems like every time I ask an actuary - any actuary - a question, they always tell me how to calculate the answer on my own.

[FlagDUDE08]

Re: The Sad Case of the Patient Protection and Affordable Care Act

Dude-i don't have that figure available. I can certainly tell you the percentage of hours spent by my office on the two. I would just love to see how much out of evry health care dollar the government and the insurance industry spends by giving it to the doctor and how much is spent in some other fashion. I think the result would be very informative.

I believe all you would have to do is read a bill that has been passed that contains the government budget. I'm sure FOIA would allow you specifics.

[DrDemento]

Re: The Sad Case of the Patient Protection and Affordable Care Act

You said that, around 2000 or so, it was 1:2, yes? I'm not saying your office is a model for the entire country, of course...

Dude-i don't have that figure available. I can certainly tell you the percentage of hours spent by my office on the two. I would just love to see how much out of evry health care dollar the government and the insurance industry spends by giving it to the doctor and how much is spent in some other fashion. I think the result would be very informative.

[DrDemento]

Re: A system that doesn't want to change

Yes, the new surgery is certainly better than the old, no question. The "problem" isn't that a new type of better, more expensive surgery is available - the problem is that surgeons realize they can make more money with the new than the old, so many/most of them stop offering the old, so then the only option becomes the new and a lot of people can't afford it. Thankfully (sarcastic), the government then steps in and mandates that insurers must cover the new surgery so that people can get knee surgery, so then there is even less incentive for doctors to offer the cheaper option, and voila, every single knee surgery costs 10x what it used to.

It would be like the government mandating that loan companies must cover loans for 200+ mph supercars (regardless of ability to pay). How many family sedans would be left on the market if the car companies knew they could make the most money by being in the supercar market?

Very perceptive and a very fair analogy.

[LynahFan]

Re: A system that doesn't want to change

Yes, this is a very concrete example that illustrates just how myopic and foolish it is to say that increases in health care costs above the rate of inflation is somehow a "problem." We are getting more in increased value in return for what we pay; ask anyone who today gets arthroscopic surgery compared to the scar that was left behind 25 years ago from knee surgery and they'll tell you that quality and value are better today relative to the cost than it was then!!

Yes, the new surgery is certainly better than the old, no question. The "problem" isn't that a new type of better, more expensive surgery is available - the problem is that surgeons realize they can make more money with the new than the old, so many/most of them stop offering the old, so then the only option becomes the new and a lot of people can't afford it. Thankfully (sarcastic), the government then steps in and mandates that insurers must cover the new surgery so that people can get knee surgery, so then there is even less incentive for doctors to offer the cheaper option, and voila, every single knee surgery costs 10x what it used to.

It would be like the government mandating that loan companies must cover loans for 200+ mph supercars (regardless of ability to pay). How many family sedans would be left on the market if the car companies knew they could make the most money by being in the supercar market?