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Much is being said of the healthcare system during this election year. Solutions to its ills are plentiful – ranging from socializing medicine to allowing \”the market to take care of things.\” Yet with all of the pundits\’ self-confident analysis as to the real problem with our healthcare system, one fact is almost never mentioned: it is not a system.
The word system is defined as:
(1) A group of interdependent items that interact regularly to perform a task.
(2) An established or organized procedure; a method. (from Webopedia)
Healthcare, is, in fact a group of entities that work largely independently and often against each other. Here is what I mean:
- Primary Care Physicians – Loners that usually don\’t hear anything when their patients are in the ER or at the specialist. They are increasingly isolated from the hospital (by using hospitalists). Pushed around by insurance and now a dying breed.
- Specialists – Cozy with the hospitals in the past. Many now do procedures in their office or surgery center they have interest in (so they get some of the money the hospitals were making off of them). Managed care has forced all referrals to go through PCP\’s, so they seldom communicate with each other.
- Emergency Departments – Where patients go when they can\’t find a PCP. High cost due to CYA (ordering extra tests to protect themselves since they don\’t see patients back), so insurance companies want everyone to avoid them. PCP\’s and specialists dump on them when too busy.
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Hospitals – They have made big money off of physicians for years, now mostly expensive patients are hospitalized. PCP\’s are given P4P bonuses for decreasing revenue of hospitals (in theory, at least).- Insurance Companies – The great Satan. The only thing unifying the other parties is their hatred of the insurance industry. The goal of insurers is to maximize shareholder value at the expense of all other parties.
- Ivory Towers – Academic medical centers are generally huge money losers that think that any physician outside of their hospital is a bad doctor and other hospitals are far inferior. Physicians in ivory towers are sheltered from reality by not having their salary really dependent on insurance. They are necessary for training of new physicians.
- Patients – Patients are the only thing #\’s 1-6 have in common. They assume the other parties are working together, but this is rarely true. They are hence the only real link between disparate information systems of the other players in healthcare. Oh yes, they are the ones for whom the others exist (even though it usually is assumed the opposite is true).
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Here are some common misconceptions about American medicine:
- Doctors and hospitals are on the same side. This is absolutely false. Hospital administrators are generally frustrated with physicians and physicians feel that hospitals are making money off of them without a return for the physician.
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Everyone likes Medicare. I have heard pundits actually say that somehow a \”Medicare for all\” would be a good thing. Medicare is the low-water mark for reimbursement for physicians who have not given it up altogether. We have a discount plan for self-pay patients in our city. To give a really bargain price, we agree to charge them only 10% above that which Medicare charges. The system would fall apart if \”Medicare for all\” happened because nobody would stay in medicine.- We know what is going on with our patients – Nobody has the big picture (except perhaps the patient). Specialists don\’t know why patients are referred; PCP\’s often don\’t know what is going on in specialists\’ offices, in the ER, or in the hospital. Medication lists changed in one location are frequently not changed in others. It is really incumbent on the patient to fill in these information gaps.
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A very large proportion of the money in our system goes to the waste that is a result of the fact that it is no system. Tests are duplicated; patients are shuttled around trusting someone knows what is going on, when they are probably the ones who know the most; doctors are not working together and hospitals are working against doctors; insurance companies have lots of information, but use it as leverage to avoid having to pay. It is chaos. It is expensive chaos.
Any steps that are taken in reforming our \”system\” must first address this chaos. How can that happen? I am not sure, but my vote would be for the two main parties: patients and doctors, to get on the same page.
Scary stuff? It should be.
Is an ivory tower doc allowed to comment? 😉
Your analysis is fabulous, if terrifying. Now, all we need to do is find a solution. Can’t be Medicare (because we won’t be able to feed our families), and it can’t be commercial insurance (because the insurance industry, as you point out, exists to make a profit for shareholders, not to provide healthcare… I mean, medical losses). So what is it?
Is an ivory tower doc allowed to comment? 😉
Your analysis is fabulous, if terrifying. Now, all we need to do is find a solution. Can’t be Medicare (because we won’t be able to feed our families), and it can’t be commercial insurance (because the insurance industry, as you point out, exists to make a profit for shareholders, not to provide healthcare… I mean, medical losses). So what is it?
It’s a good thing that there appears to be a neverending stream of fresh faced young medical students and bleary eyed residents to train or else I would be entirely obsolete. I get the point Dr. Rob. Academic physicians, myself included, do tend to become a tad cynical at times, but you seem to imply that this is somehow a character flaw unique to us and not understandable, if not justified.
In my experience(most dangerous words in medicine by the way), many of the primary care physicians I encounter, and that is quite a few on a daily basis, think that every doctor other than themselves is a bad doctor and that academic hospitals are bad because they overdo things. Somehow this never seems to stop them from sending their kids to the ER for every white count above (insert randomly chosen cut-off) or calling my wife at all hours of the night to ask questions that could be answered with a google search. You left the PCP’s blatant misuse of the academic center out of your description.
You failed to mention that academic facilities, at least in the two large centers I have trained and/or worked in, are where children, in my particular area of practice, tend to end up when their PCP, if they have one, or an outside facility doesn’t know what to do. That however typically doesn’t stop them from trying any number of things which, to the best of my knowledge, were buried somewhere deep inside their rectum. And it certainly doesn’t stop them from making unreasonable demands of the academic ER physicans either.
I understand fully that selection bias is at least partially at play here since we don’t tend to see the kids where everything has been going peachy but I have personally seen enough infants on zithromax for sinusitis, toddlers on PO albuterol for cough, and newborn infants on afrin for their loud breathing to grasp that there are a lot of bad primary care doctors out there who think that reading the cover of the latest throwaway is keeping up with the literature. And when things are going peachy rarely is that attributable to anything the PCP did because the majority of pediatric illness is self-limited.
I agree that there are times when the literature is not clear on what to do, and that in these situations there is more than one right answer. When that happens, and the patient ends up at an ivory tower, there will always be generalists and specialists at academic hospitals that equate “not what I would have done” with being wrong. This clearly isn’t always the case and is unfair. But I don’t think you fully grasp just how often that what is being done out there in “reality” is just plain wrong and isn’t up for debate.
Clearly, I am biased against the practice of primary care medicine. Not primary care practitioners (really) but the job itself. It isn’t for me which is why I have chosen to stay in the academic setting. But you are also biased in favor of what you do, which is clear in your description of ivory towers and of primary care docs as poor innocent victims of a non-system. My reality, sheltered though it may be, is not so black and white.
It’s a good thing that there appears to be a neverending stream of fresh faced young medical students and bleary eyed residents to train or else I would be entirely obsolete. I get the point Dr. Rob. Academic physicians, myself included, do tend to become a tad cynical at times, but you seem to imply that this is somehow a character flaw unique to us and not understandable, if not justified.
In my experience(most dangerous words in medicine by the way), many of the primary care physicians I encounter, and that is quite a few on a daily basis, think that every doctor other than themselves is a bad doctor and that academic hospitals are bad because they overdo things. Somehow this never seems to stop them from sending their kids to the ER for every white count above (insert randomly chosen cut-off) or calling my wife at all hours of the night to ask questions that could be answered with a google search. You left the PCP’s blatant misuse of the academic center out of your description.
You failed to mention that academic facilities, at least in the two large centers I have trained and/or worked in, are where children, in my particular area of practice, tend to end up when their PCP, if they have one, or an outside facility doesn’t know what to do. That however typically doesn’t stop them from trying any number of things which, to the best of my knowledge, were buried somewhere deep inside their rectum. And it certainly doesn’t stop them from making unreasonable demands of the academic ER physicans either.
I understand fully that selection bias is at least partially at play here since we don’t tend to see the kids where everything has been going peachy but I have personally seen enough infants on zithromax for sinusitis, toddlers on PO albuterol for cough, and newborn infants on afrin for their loud breathing to grasp that there are a lot of bad primary care doctors out there who think that reading the cover of the latest throwaway is keeping up with the literature. And when things are going peachy rarely is that attributable to anything the PCP did because the majority of pediatric illness is self-limited.
I agree that there are times when the literature is not clear on what to do, and that in these situations there is more than one right answer. When that happens, and the patient ends up at an ivory tower, there will always be generalists and specialists at academic hospitals that equate “not what I would have done” with being wrong. This clearly isn’t always the case and is unfair. But I don’t think you fully grasp just how often that what is being done out there in “reality” is just plain wrong and isn’t up for debate.
Clearly, I am biased against the practice of primary care medicine. Not primary care practitioners (really) but the job itself. It isn’t for me which is why I have chosen to stay in the academic setting. But you are also biased in favor of what you do, which is clear in your description of ivory towers and of primary care docs as poor innocent victims of a non-system. My reality, sheltered though it may be, is not so black and white.
The system would fall apart if “Medicare for all” happened because nobody would stay in medicine.
Thanks for pointing this out. The whole “medicare is a success” meme is one of those myths that is almost impossible to kill, no matter how many facts you hit it with. In reality, of course, it is a regulatory and reimbursement nightmare that has damaged health care immensely already.
The system would fall apart if “Medicare for all” happened because nobody would stay in medicine.
Thanks for pointing this out. The whole “medicare is a success” meme is one of those myths that is almost impossible to kill, no matter how many facts you hit it with. In reality, of course, it is a regulatory and reimbursement nightmare that has damaged health care immensely already.
All too true. I think one of the factors contributing to no one knowing the full picture is that the fact the physicians that should be the wrangler is overloaded. From my personal observation PCPs have far higher patient load than specialists. So how are they supposed to handle their normal everyday patient load plus the specialists each patient has?
All too true. I think one of the factors contributing to no one knowing the full picture is that the fact the physicians that should be the wrangler is overloaded. From my personal observation PCPs have far higher patient load than specialists. So how are they supposed to handle their normal everyday patient load plus the specialists each patient has?
I agree that the “middlemen” have damaged the doctor-patient relationship, that our primary care base must be invested in heavily, that people need a medical home through which care may be coordinated. Privacy issues aside, my bet is on creating a patient-controlled digital medical home where all specialists and PCPs get on the same online page. Our broken “system” will not soon be fixed – we need to empower patients with a navigation system (an “OnStar” for health) and that’s what I’m trying to do at Revolution Health. Conceptually, building a GPS for healthcare is exactly what we need IMO.
I agree that the “middlemen” have damaged the doctor-patient relationship, that our primary care base must be invested in heavily, that people need a medical home through which care may be coordinated. Privacy issues aside, my bet is on creating a patient-controlled digital medical home where all specialists and PCPs get on the same online page. Our broken “system” will not soon be fixed – we need to empower patients with a navigation system (an “OnStar” for health) and that’s what I’m trying to do at Revolution Health. Conceptually, building a GPS for healthcare is exactly what we need IMO.
I know I painted academic centers with a broad brush, just as you, Clay, paint PCP’s. For the reasonable PCP’s the academic centers seem distrustful – I use them only when I must, but then they try to steer people from my care. The bad docs are just as happy, since they don’t really much care about doing quality work and the ivory towers will take work off of their hands. The bottom line is that there is no good system in place to move patients between the two.
Regarding what is to be done? I am probably going to blog on that in the future, but basically it must start with a national medical online health network. We must have a “single chart” we all have access to so we can stop this choppy care.
I know I painted academic centers with a broad brush, just as you, Clay, paint PCP’s. For the reasonable PCP’s the academic centers seem distrustful – I use them only when I must, but then they try to steer people from my care. The bad docs are just as happy, since they don’t really much care about doing quality work and the ivory towers will take work off of their hands. The bottom line is that there is no good system in place to move patients between the two.
Regarding what is to be done? I am probably going to blog on that in the future, but basically it must start with a national medical online health network. We must have a “single chart” we all have access to so we can stop this choppy care.
I agree that academic centers probably are at times distrustful. This is likely based on communication issues as well as a significant amount of past experience. I think that the bad pediatricians far outweigh the good. And by bad I mostly mean lazy. Lazy medicine is what frustrates me more than anything else, especially in an era when the answers are a google search away in most instances. Far too many doctors, whether academic or “reality” based (but I have no doubt it is worse in the real world), are just plain lazy.
I am skeptical of your concerns regarding academic care if you mean them to apply to pediatrics in the same way you do adult medicine. Since you are involved in the care of both children and adults, perhaps you could be more specific. Do the concerns you raise apply to all areas of medicine or is there a difference when it comes to pediatric medicine in your opinion?
The private pediatricians I know are happy, work 4 days a week, and make a lot more money than I do working more hours and taking overnight call. In general, academic specialists and generalists make significantly less money than PCP’s and work longer hours often with overnight call. Is this mass PCP extinction, something I’ve not seen evidence for in pediatrics (doesn’t mean there isn’t any, I just haven’t seen it), specific to adult medicine? The last I heard, there were shortages of pediatric subspecialists in many areas because people would rather go into private practice, make more money, and live higher quality lives.
I agree that academic centers probably are at times distrustful. This is likely based on communication issues as well as a significant amount of past experience. I think that the bad pediatricians far outweigh the good. And by bad I mostly mean lazy. Lazy medicine is what frustrates me more than anything else, especially in an era when the answers are a google search away in most instances. Far too many doctors, whether academic or “reality” based (but I have no doubt it is worse in the real world), are just plain lazy.
I am skeptical of your concerns regarding academic care if you mean them to apply to pediatrics in the same way you do adult medicine. Since you are involved in the care of both children and adults, perhaps you could be more specific. Do the concerns you raise apply to all areas of medicine or is there a difference when it comes to pediatric medicine in your opinion?
The private pediatricians I know are happy, work 4 days a week, and make a lot more money than I do working more hours and taking overnight call. In general, academic specialists and generalists make significantly less money than PCP’s and work longer hours often with overnight call. Is this mass PCP extinction, something I’ve not seen evidence for in pediatrics (doesn’t mean there isn’t any, I just haven’t seen it), specific to adult medicine? The last I heard, there were shortages of pediatric subspecialists in many areas because people would rather go into private practice, make more money, and live higher quality lives.
I suspect many would dispute the statement “bad pediatricians far outweigh the good.” Most community pediatricians are earning between 120-130K per year and seeing 30-40 patients per day and working 50-60 hours/week. Most work an after hours clinic as well and round early in the day. In our city, it is for the lifestyle that doctors go to the Academic setting (not the salary). It is very hard to make lots of money in the private sector of medicine (despite the shortage). Perhaps things are very different in your community than ours, but I don’t think lazy doctors here work for very long (they go out of business).
There clearly is a little more communication from the academics in pediatrics, although I would say that they are probably more likely in our city to see themselves as superior to us. With many of the Peds subspecialists in town, I talk to them on the phone myself (and they are very gracious in that way). For adult patients, I have more private subspecialists that I can refer to, so I tend not to use the academic center except in specific areas of expertise.
I suspect many would dispute the statement “bad pediatricians far outweigh the good.” Most community pediatricians are earning between 120-130K per year and seeing 30-40 patients per day and working 50-60 hours/week. Most work an after hours clinic as well and round early in the day. In our city, it is for the lifestyle that doctors go to the Academic setting (not the salary). It is very hard to make lots of money in the private sector of medicine (despite the shortage). Perhaps things are very different in your community than ours, but I don’t think lazy doctors here work for very long (they go out of business).
There clearly is a little more communication from the academics in pediatrics, although I would say that they are probably more likely in our city to see themselves as superior to us. With many of the Peds subspecialists in town, I talk to them on the phone myself (and they are very gracious in that way). For adult patients, I have more private subspecialists that I can refer to, so I tend not to use the academic center except in specific areas of expertise.
I am not a Dr. rather a patient of a disorder called Mal de Debarquement of which none of the above can provide an answer or even interested in finding an answer.
I am not a Dr. rather a patient of a disorder called Mal de Debarquement of which none of the above can provide an answer or even interested in finding an answer.
That’s great money and good hours, and sounds on par with my neck of the woods. I make significantly less than that and work a little bit more (60-70 hours/week including on average one overnight call/week). I don’t have to pay for my malpractice which is nice though.
I should have been more clear in that I meant that there are more intellecutally lazy pediatricians, which is what I mean by bad. I do not think that there are a lot of dangerous pediatricans. It is easier to just write a scrip for augmentin than to try and reason with a parent who wants antibiotics for their child’s cold, or to go with a diagnosis/work-up that isn’t exactly clear or necessary instead of taking the time to do some research. And I dont’ mean going to the local medical library during lunch either. I mean google. I have lost track of how many times 5 minutes on the internet has saved a patient of mine an uneccessary blood draw, helped me to better focus an imaging work-up, or allowed me to avoid calling a grumpy renal fellow.
That’s great money and good hours, and sounds on par with my neck of the woods. I make significantly less than that and work a little bit more (60-70 hours/week including on average one overnight call/week). I don’t have to pay for my malpractice which is nice though.
I should have been more clear in that I meant that there are more intellecutally lazy pediatricians, which is what I mean by bad. I do not think that there are a lot of dangerous pediatricans. It is easier to just write a scrip for augmentin than to try and reason with a parent who wants antibiotics for their child’s cold, or to go with a diagnosis/work-up that isn’t exactly clear or necessary instead of taking the time to do some research. And I dont’ mean going to the local medical library during lunch either. I mean google. I have lost track of how many times 5 minutes on the internet has saved a patient of mine an uneccessary blood draw, helped me to better focus an imaging work-up, or allowed me to avoid calling a grumpy renal fellow.
So… would this be a good time to go into medicine -_-?
So… would this be a good time to go into medicine -_-?
As a job, it can’t be beat. As a business, it leaves much to be desired. Things will be greatly changed when you would start practicing, so it may be better, but it may be worse. I personally would ever find it hard to find a better job. I just love the work, and we are smart enough to make the business side still work OK.
As a job, it can’t be beat. As a business, it leaves much to be desired. Things will be greatly changed when you would start practicing, so it may be better, but it may be worse. I personally would ever find it hard to find a better job. I just love the work, and we are smart enough to make the business side still work OK.
In acute psychiatric hospitals, we are lucky to be able to talk to any doctor who has previously treated the patient in any setting. Part of this results from asking psychotic people to sign releases, but much of it seems to come from unconcern.
In acute psychiatric hospitals, we are lucky to be able to talk to any doctor who has previously treated the patient in any setting. Part of this results from asking psychotic people to sign releases, but much of it seems to come from unconcern.
Rob this was a very interesting post as were the comments.
How can I as a pt insure that my docs and I are on the same page?
My autoimmune doctor likes every test result that I have from seeing other doctors sent to him so that if something were wrong he could put the whole picture together. He is the only doctor I know that does that.
Rob this was a very interesting post as were the comments.
How can I as a pt insure that my docs and I are on the same page?
My autoimmune doctor likes every test result that I have from seeing other doctors sent to him so that if something were wrong he could put the whole picture together. He is the only doctor I know that does that.
This was a good post, Rob. We can even see right here how patients can be caught in the middle just watching something back and forth. We need to be on the same page as our physicians – I totally agree. I think it would be an easier time of getting that accomplished than getting the physicians to appreciate each other’s positions and concentrate only on their role for the patient’s sake. I don’t like when a specialist has made snide comments about my PCP, feeling they knew better…when as it’s turned out my PCP was spot on – I found a new specialist. We need them to work together, not play who’s the better doc.
This was a good post, Rob. We can even see right here how patients can be caught in the middle just watching something back and forth. We need to be on the same page as our physicians – I totally agree. I think it would be an easier time of getting that accomplished than getting the physicians to appreciate each other’s positions and concentrate only on their role for the patient’s sake. I don’t like when a specialist has made snide comments about my PCP, feeling they knew better…when as it’s turned out my PCP was spot on – I found a new specialist. We need them to work together, not play who’s the better doc.
Unbelievably spot-on. My recent medical experience (in the US) beautifully corroborates 5/7 you list: two specialists, a battery of tests (which the specialists disagreed on via me, not directly with one another), a surgery which, despite extremely careful i-dotting and t-crossing to make sure I was covered by insurance for, is nevertheless not being fully covered by my insurance (they’re denying payment to the surgical assistant), and finally my wonderful PCP – who apparently (I just found out) never learned that I had a complete thyroidectomy last December that resulted from HER thoroughness in a basic exam last spring. Kinda crazy. They were all great docs in their own right, but I mean… who’s in charge here? Apparently me. Hope none of them take offense when I ask for complete copies of all my medical records.
Unbelievably spot-on. My recent medical experience (in the US) beautifully corroborates 5/7 you list: two specialists, a battery of tests (which the specialists disagreed on via me, not directly with one another), a surgery which, despite extremely careful i-dotting and t-crossing to make sure I was covered by insurance for, is nevertheless not being fully covered by my insurance (they’re denying payment to the surgical assistant), and finally my wonderful PCP – who apparently (I just found out) never learned that I had a complete thyroidectomy last December that resulted from HER thoroughness in a basic exam last spring. Kinda crazy. They were all great docs in their own right, but I mean… who’s in charge here? Apparently me. Hope none of them take offense when I ask for complete copies of all my medical records.
You really pegged it, Rob. I agree, agree agree. Nothing more to say. Wish I would have said it first.
You really pegged it, Rob. I agree, agree agree. Nothing more to say. Wish I would have said it first.
I hate to tell you this, but if there really was “Medicare for all” then a lot more of you would stay in medicine and in the system than you think. You’re highly skilled professionals and very intelligent, but you don’t actually as much leverage or life options as you think you do. That’s not a threat, just an observation from the life of other physicians around the world. It’s no fun, but it is true.
I hate to tell you this, but if there really was “Medicare for all” then a lot more of you would stay in medicine and in the system than you think. You’re highly skilled professionals and very intelligent, but you don’t actually as much leverage or life options as you think you do. That’s not a threat, just an observation from the life of other physicians around the world. It’s no fun, but it is true.
Primary care would become absolutely scarce. We absolutely could not stay in business. There would have to be some other business model to come up and fix it or they would have to shift money away from specialists to avoid losing primary care physicians. They would not be happy about that. Truly, we lose money on many of our Medicare patients. Businesses don’t function like that.
Primary care would become absolutely scarce. We absolutely could not stay in business. There would have to be some other business model to come up and fix it or they would have to shift money away from specialists to avoid losing primary care physicians. They would not be happy about that. Truly, we lose money on many of our Medicare patients. Businesses don’t function like that.
I’m being a spoilsport here, but why didn’t you include nurses and nursing in the healthcare system? Nursing directly affects patient morbidity and mortaily, not to mention whether or not patients meet expected desired outcomes. The NYTimes reported on the CMS patent satisfaction/quality perception hospital reporting, and reader comments ran strongly to preventable errors and dissatisfaction with nurses and nursing (link at my name). Yet the Times doesn’t ever report nursing issues or use nurse experts.
A few days earlier, a physician blogged ostensibly about medical errors, yet used multiple examples of nursing errors. Why is it when error and failures are mentioned, physicians immediately cite nurses and nursing?
I’m being a spoilsport here, but why didn’t you include nurses and nursing in the healthcare system? Nursing directly affects patient morbidity and mortaily, not to mention whether or not patients meet expected desired outcomes. The NYTimes reported on the CMS patent satisfaction/quality perception hospital reporting, and reader comments ran strongly to preventable errors and dissatisfaction with nurses and nursing (link at my name). Yet the Times doesn’t ever report nursing issues or use nurse experts.
A few days earlier, a physician blogged ostensibly about medical errors, yet used multiple examples of nursing errors. Why is it when error and failures are mentioned, physicians immediately cite nurses and nursing?
Good one moose. It is probably telltale of the problem in that I omitted it. Communication between doctors and nurses is a huge problem and hospital administrators seem to view nurses as expendable overhead and not what they really are: their core business. Hospitals are about nursing, but most administrators don’t realize that. Nurses are about the delivery of healthcare – they are often the ones who take the fall in situations that you highlighted. Yet the whole point of my post was to highlight the fact that there are many levels of medical mishaps – all of which cost money and are harmful to patients.
To answer your question, it is because physicians would rather pass the buck than clean up their own mess.
Good one moose. It is probably telltale of the problem in that I omitted it. Communication between doctors and nurses is a huge problem and hospital administrators seem to view nurses as expendable overhead and not what they really are: their core business. Hospitals are about nursing, but most administrators don’t realize that. Nurses are about the delivery of healthcare – they are often the ones who take the fall in situations that you highlighted. Yet the whole point of my post was to highlight the fact that there are many levels of medical mishaps – all of which cost money and are harmful to patients.
To answer your question, it is because physicians would rather pass the buck than clean up their own mess.
I am a primary care physician starting a cash-only retainer based practice. I have been out of residency for 2 years and I have learned one thing. Insurance companies, other doctors, or hospitals don’t give a crap about my school debt, my mortgage, my retirement, or my kids college tuition. I am looking out for myself and family first then my patients and that’s it. Afer that I am going to move to the beach and drink coronas and fart and watch this country implode on itself. SEE YA
I am a primary care physician starting a cash-only retainer based practice. I have been out of residency for 2 years and I have learned one thing. Insurance companies, other doctors, or hospitals don’t give a crap about my school debt, my mortgage, my retirement, or my kids college tuition. I am looking out for myself and family first then my patients and that’s it. Afer that I am going to move to the beach and drink coronas and fart and watch this country implode on itself. SEE YA
Agreed re the larger point of not a cohesive system. Disagree re the incidental point on medicare. First of all, Medicare is not the low point for reimbursement, medicaid is. But that’s a minor quibble.
I admit that I don’t know squat about other specialties. But in EM, medicare reimbursement is not far from the blended average reimbursement. If Medicare is paying $39/rvu, most practices have a across-the-board reimbursement of $40-$45/rvu. You mileage may vary depending on location and payer mix. My point here is that if every patient had medicare, there were no medicaid or uninsured patients, the average hit for EM docs would be 15% of gross revenue, in part made up by the absence of denials, contracting, and admin overhead that the private payers obligate. It would be a hit, but a small one.
Maybe this is not true for office-based practices, where you have the option of sending away a large fraction of the uninsured. maybe a medicare for all system would be catastrophic — I honestly don’t know. But for EM, it would be a small hit only. So don’t oversell the “Medicare suxx” theme too much.
Agreed re the larger point of not a cohesive system. Disagree re the incidental point on medicare. First of all, Medicare is not the low point for reimbursement, medicaid is. But that’s a minor quibble.
I admit that I don’t know squat about other specialties. But in EM, medicare reimbursement is not far from the blended average reimbursement. If Medicare is paying $39/rvu, most practices have a across-the-board reimbursement of $40-$45/rvu. You mileage may vary depending on location and payer mix. My point here is that if every patient had medicare, there were no medicaid or uninsured patients, the average hit for EM docs would be 15% of gross revenue, in part made up by the absence of denials, contracting, and admin overhead that the private payers obligate. It would be a hit, but a small one.
Maybe this is not true for office-based practices, where you have the option of sending away a large fraction of the uninsured. maybe a medicare for all system would be catastrophic — I honestly don’t know. But for EM, it would be a small hit only. So don’t oversell the “Medicare suxx” theme too much.
Very well put. One good thing that comes out of all of this mess….I keep job security as a case manager because I am often the only one that has a handle on what is going on with my patients. As a nurse I do see the delivery of healthcare (often really good care) and also recognize the gaps before they get too large. Patients no longer get the face-to-face time they need to answer their multitude of questions. Their questions are also more plentiful due to the internet. Patients lack the understanding and record keeping required for their own best health. My record keeping of multiple providers and appointments helps keep all parties informed as to what is going on and prevent unnecessary duplication of services. Now if everyone just had their own case manager…..
Very well put. One good thing that comes out of all of this mess….I keep job security as a case manager because I am often the only one that has a handle on what is going on with my patients. As a nurse I do see the delivery of healthcare (often really good care) and also recognize the gaps before they get too large. Patients no longer get the face-to-face time they need to answer their multitude of questions. Their questions are also more plentiful due to the internet. Patients lack the understanding and record keeping required for their own best health. My record keeping of multiple providers and appointments helps keep all parties informed as to what is going on and prevent unnecessary duplication of services. Now if everyone just had their own case manager…..
Love your wit and insights…
Agree with your premise completely. The key question for mois, is how do we avoid the “unintended consequences” of implementing needed health reform?
The “sausage grind”, best intentions not withstanding, from intent, to law to regs often corrupt the will of the architects.
Write on…..we are kindred spirits!
Love your wit and insights…
Agree with your premise completely. The key question for mois, is how do we avoid the “unintended consequences” of implementing needed health reform?
The “sausage grind”, best intentions not withstanding, from intent, to law to regs often corrupt the will of the architects.
Write on…..we are kindred spirits!