Re: The Sad Case of the Patient Protection and Affordable Care Act
This isn't news. It isn't even old news. Specialists get paid sig more and have way less responsibility in the current system. The primary care people are getting more and more responsibility and no renumeration to go with it. Mass had an immediate shortage that persists in primary care. If a practice is any good it rarely is open to new patients in our area.
Until they start paying the primary practice for all the things they think we should do this will persist. Why does an ENT's med asst get paid 250 to irrigate and ear and we get 80$? Our reimbursement for care is not as high as the specialist. Top that with all the punishments the insurance companies heap on us if the patient is non-compliant and we practically pay to take care of the pt. See various rants in this and previous threads
Was not going to join the chat but Les always makes me do some thinking. Why do we have this wide differencial in remuneration for physicians? Who made up the numbers and who decided what each tiny little thing we did got paid for and how much? Who assigned codes for everything and who decided what the remuneration was for each carefully coded item? Did practicing physicians cause this situation or even play a big part in it? Anyone with medical practice experience will tell you how ridiculous this entire system of coding and reimbursement is. Even trying to figure out how to do this properly and adhere to the coding guidelines often causes an office to hire someone just for that purpose. And then once you have it down pat, stupid as it may be, they change it and you have to learn all new codes and their uses.
From personal experience-whoever devised this wonderful system decided that i should be reimbursed more for taking off a benign tiny growth on the face than I received for doing a much more complicated excision of a cancer on the chest(which also necessitated far more time and expertise and careful follow up visits).
Doctors are not stupid people (except when it comes to investing and perhaps politics)
So they quickly figured that you could spend a morning as a gastroenterologist doing a series of expensively reimbursed procedures (endoscopies, colonoscopies, etc) at their local outpatient surgical facility and collect a tidy sum of money versus spending all day in the office with patients taking medical histories, doing physical exams, and prescribing and counseling and collect 1/10th or less in revenue. Now, what would you choose? 3 hours performing 6 of these 20-30 minute procedures at a couple thousand each or spending all day seeing 40 patients in the office at perhaps $50 a piece? I used gastroenterology as an example but the same thing virtually happens with almost any specialty. The things that the coding system rewards are the things that the doctors are going to try to do more often-sometimes even when they are not needed.
Primary care physicians usually do not have that luxury-most of what they do is see a patient, take a history, perform a physical examination, and then either counsel or prescribe. But all of that takes considerable time and because the coding only allows the entire time as an office visit (between level 1 and 5 in value depending on all sorts of factors that make very little sense-since often they do not reflect the seriousness of the problem). Who, beside the truly devoted, would ever make the choice to enter the field of primary practice medicine when they had the choice to work less hours, see less people, perform more procedures and receive an incredibly larger amount of money for doing it?
I do not dare suggest that I have the solution to this problem. But certainly having these decisions about reimbursement left to people who have no clue about the practice of medicine. Or to people who have a financial interest in these decisions (insurance companies, the government, etc) just has not worked. Way back in the old days-before all of this coding and reimbursement being based on criteria that make little sense-specialists still made a better living than primary care physicians. That was probably the case ever since the age of specialization began. But the differential was not nearly as great. When I graduated medical school-40+ years ago-about 1/2 our graduating class intended to be primary physicians. If i was able to go back further perhaps that figure would have even been higher. Today, the number who even consider it has dwindled to a minute percentage.
