House of Cards

\"houseofcards\" I was sitting in a conference recently;  the speaker was talking about the Medical Home and how one practice was getting nearly $150K for managing a patient population using a new computerized tool.  Sounds good.
During the question and answer period I asked the speaker:  \”Shouldn\’t we wait until insurance companies are willing to pay for this before adopting it?  If we start giving this care on our own, what motivation will they have to pay us for doing it?\”

The speaker smiled and agreed that the \”market would have to mature\” before this technology could be adopted.  If we do adopt too soon, we run the risk of giving higher quality for nothing.  We do extra work – above and beyond what we are doing now – and do so \”for the good of the patients.\”  Yet while the patients and payers benefit, our hourly rate goes down.

Sad.

Here is a technology that improves care and potentially saves lives, and yet we are waiting for a good business case to do it.  Only in America.

A physician came up to me after the talk and said, \”No matter what happens, we physicians are going to get screwed.\”

That is the climate we practice in.  Morale has never been lower among physicians.  We are all tired of bearing the responsibility for change without sharing in its fruits.  Any new program that comes along is suspect.  Where\’s the catch?  How is this \”great new idea\” going to lower my bottom line?

Why can\’t we just get paid for doing a better job?

Let me make this clear:  I do whatever I can to maintain the best quality care for my patients as is possible.  I am proud of the quality I do.  Our practice has actually surpassed most reported quality numbers by far.  We do well despite this climate.  But the rank-and file physician is frustrated with having to choose between good care and good business.

I really see an attitude – especially among primary care physicians – of resignation.  I think a bunch of doctors are on the verge of either totally dropping insurance, or quitting medicine altogether.  This will make an already bad situation for patients disastrous.  Sometimes I even wonder why my practice keeps accepting insurance.  It certainly is not because it is a wise business move.

Note to politicians:  be careful what you do.  A bunch of physicians are hanging by a thread.  They are tired and cynical.  Make the wrong move and the whole house of cards will crash.

Some \”insiders\” have told me that the folks in Washington really get it, and primary care is about to get a really big boost.  Well, I hope so.  But I am not keeping my hopes too high.  I am planning for the worst.

And I am one of the more optimistic physicians.

Really.

41 thoughts on “House of Cards”

  1. I find it difficult to fathom how politicians cannot understand the shortcomings of the healthcare system in this country. Punishing doctors to put a band-aid over a gaping wound is not an acceptable solution. In addition to your statement about physicians hanging by a thread: I have been told by several physicians to reconsider my decision to pursue medicine. Making the field unappetizing for future physicians will backfire also. Here’s to putting full faith in our politicians.

  2. I find it difficult to fathom how politicians cannot understand the shortcomings of the healthcare system in this country. Punishing doctors to put a band-aid over a gaping wound is not an acceptable solution. In addition to your statement about physicians hanging by a thread: I have been told by several physicians to reconsider my decision to pursue medicine. Making the field unappetizing for future physicians will backfire also. Here’s to putting full faith in our politicians.

  3. Dr. Rob, why are you waiting for insurance to pay for the patient management system? In my business, if I want to stay competitive and efficient, I need to invest my $$$ and time into keeping up. $150,000? Big deal. We paid $12,000 for job tracking software, and pay over $1,500. per month just in support fees. It is the cost of doing business. My company just invested $225,000 in one new machine to replace and update an older machine. The older machine was paid for 5 years ago and still worked just fine. Why replace it? Because the new machine was faster, has more features and could multi-task. Big investment, yet If we don’t do it, then someone else who does will be more competitive in delivery, price and quality. No waiting for insurance or gov’t to spend the cash for us.Sometimes it sounds and feels as if the insurance company is the mob, and the pcp is the legit front man.

  4. Dr. Rob, why are you waiting for insurance to pay for the patient management system? In my business, if I want to stay competitive and efficient, I need to invest my $$$ and time into keeping up. $150,000? Big deal. We paid $12,000 for job tracking software, and pay over $1,500. per month just in support fees. It is the cost of doing business. My company just invested $225,000 in one new machine to replace and update an older machine. The older machine was paid for 5 years ago and still worked just fine. Why replace it? Because the new machine was faster, has more features and could multi-task. Big investment, yet If we don’t do it, then someone else who does will be more competitive in delivery, price and quality. No waiting for insurance or gov’t to spend the cash for us.Sometimes it sounds and feels as if the insurance company is the mob, and the pcp is the legit front man.

  5. Philb, I think you’ve misunderstood the point here. In PHC all the drivers are to “do a good enough job for minimum cost”, whereas in machine shops the drivers are to be, as you say, faster, cheaper and better quality.

  6. Philb, I think you’ve misunderstood the point here. In PHC all the drivers are to “do a good enough job for minimum cost”, whereas in machine shops the drivers are to be, as you say, faster, cheaper and better quality.

  7. It’s hard to overstate the despair that sets in when someone spends 7 years of his/her life in intense medical training, gets 200,000 dollars or so in debt, and then realizes, in many ways, the job sucks. First anger sets in (why didn’t someone tell me to do something else?), then denial (it’s really not that bad, things are going to improve, right?), then finally resignation that it is what it is.
    It’s certainly disheartening to admit that your life calling isn’t what you thought it was. Either resign yourself to real world primary care medicine, or start thinking about doing something else. (it is frightening how many PCPs are thinking seriously about finding something else to do) I hope a 3rd choice is an option soon. If not, at least we can say “I told you so” when that house of cards falls.

  8. It’s hard to overstate the despair that sets in when someone spends 7 years of his/her life in intense medical training, gets 200,000 dollars or so in debt, and then realizes, in many ways, the job sucks. First anger sets in (why didn’t someone tell me to do something else?), then denial (it’s really not that bad, things are going to improve, right?), then finally resignation that it is what it is.
    It’s certainly disheartening to admit that your life calling isn’t what you thought it was. Either resign yourself to real world primary care medicine, or start thinking about doing something else. (it is frightening how many PCPs are thinking seriously about finding something else to do) I hope a 3rd choice is an option soon. If not, at least we can say “I told you so” when that house of cards falls.

  9. Healthcare Today

    House of Cards…
    “No matter what happens, we physicians are going to get screwed.”

    That is the climate we practice in. Morale has never been lower among physicians. We are all tired of bearing the responsibility for change without sharing in its fruits. Any new p…

  10. I see the point well enough, just trying to spin the concept in my head. Who ultimately foots the bill for upgrading to better, faster more accurate technology? The customer does. The cost may be substantial upfront for the provider, but any good businessman knows that such investment will pay for itself.I am not sure how a pcp office differs from any other small business, except that the doctor is himself the primary asset. How many docs forget the rest of the business and try to spend as little money as possible on support and technology in an futile effort to keep costs down and maximize profit? If that is the case then the business is already losing money.

  11. I see the point well enough, just trying to spin the concept in my head. Who ultimately foots the bill for upgrading to better, faster more accurate technology? The customer does. The cost may be substantial upfront for the provider, but any good businessman knows that such investment will pay for itself.I am not sure how a pcp office differs from any other small business, except that the doctor is himself the primary asset. How many docs forget the rest of the business and try to spend as little money as possible on support and technology in an futile effort to keep costs down and maximize profit? If that is the case then the business is already losing money.

  12. Philb you make a valid point that the PCP is the asset however, you forget the BIG difference between medicine business[MB] and a regular business[RB]. In an RB you decide what your product is worth, in an MB someone else does ie insurance, medicaid, medicare.
    In an RB a new investment leads to growth b/c it allows you to do what you are doing better and you are able to charge your customers more for that better product. In an MB new investment –> improved product –> no change in payment because well….you don’t decide how much you get paid…..someone else does.

  13. Philb you make a valid point that the PCP is the asset however, you forget the BIG difference between medicine business[MB] and a regular business[RB]. In an RB you decide what your product is worth, in an MB someone else does ie insurance, medicaid, medicare.
    In an RB a new investment leads to growth b/c it allows you to do what you are doing better and you are able to charge your customers more for that better product. In an MB new investment –> improved product –> no change in payment because well….you don’t decide how much you get paid…..someone else does.

  14. “No matter what happens, we physicians are going to get screwed.”
    That’s what I hear every time I goto my professional conferences except obviously physicians are replaced by what I am. There maybe at most 1000 people in the US that do what I am… it’s difficult to get our voices heard. It’s disheartening, being relatively young in my field to head into what appears to be the path to doom. But people who are saying this are people who’ve seen ‘better times’ so maybe I won’t think it’s so bad.

    Recently, the congress tried passing a bill that’d have a drastic negative impact on my and creative artistic professions in general. Well…the bill’s been in the works for a few years but anyway… The bill was going to get fast-tracked/voted last month, as of now it’s on hold. It did take years of efforts of artist groups from all over the country (and internationally) to get it to that point.

  15. “No matter what happens, we physicians are going to get screwed.”
    That’s what I hear every time I goto my professional conferences except obviously physicians are replaced by what I am. There maybe at most 1000 people in the US that do what I am… it’s difficult to get our voices heard. It’s disheartening, being relatively young in my field to head into what appears to be the path to doom. But people who are saying this are people who’ve seen ‘better times’ so maybe I won’t think it’s so bad.

    Recently, the congress tried passing a bill that’d have a drastic negative impact on my and creative artistic professions in general. Well…the bill’s been in the works for a few years but anyway… The bill was going to get fast-tracked/voted last month, as of now it’s on hold. It did take years of efforts of artist groups from all over the country (and internationally) to get it to that point.

  16. mottsapplesauce

    Phil,You sound exactly like our budget director, who can’t totally grasp why our healthcare business struggles to make a profit. Patients are not widgets. You can’t compare the two. Insurance companies have you by the nads if you contract with them & they can take several months to pay a claim, while the provider has to keep paying the same amount to have that claim reworked & reworked & reworked, etc….. Not every healthcare provider has the ability to opt out & survive on cash-only clients.

  17. mottsapplesauce

    Phil,You sound exactly like our budget director, who can’t totally grasp why our healthcare business struggles to make a profit. Patients are not widgets. You can’t compare the two. Insurance companies have you by the nads if you contract with them & they can take several months to pay a claim, while the provider has to keep paying the same amount to have that claim reworked & reworked & reworked, etc….. Not every healthcare provider has the ability to opt out & survive on cash-only clients.

  18. some dude named steevo

    I would definitely consider another career, even if it involved a pay cut. I am already in the process of ceasing to deliver babies. It no longer makes economic sense and the lifestyle has become tiring. I have been looking around, but it seems while there is currently a shortage of primary care physicians, there is NO shortage of physicians looking for non-healthcare careers.
    I am glad I discovered your blog through the Well blog at NY Times. However, I think I am going to have to stop reading The Well due to all the posters on there, they are the negative 1% that sap my soul.

    Dr. Rob, do you know Yevgeny Kilman?

  19. some dude named steevo

    I would definitely consider another career, even if it involved a pay cut. I am already in the process of ceasing to deliver babies. It no longer makes economic sense and the lifestyle has become tiring. I have been looking around, but it seems while there is currently a shortage of primary care physicians, there is NO shortage of physicians looking for non-healthcare careers.
    I am glad I discovered your blog through the Well blog at NY Times. However, I think I am going to have to stop reading The Well due to all the posters on there, they are the negative 1% that sap my soul.

    Dr. Rob, do you know Yevgeny Kilman?

  20. Steevo, I’m sorry you feel that way, but I certainly understand. Very much.
    I have two questions for you:

    1) What would it take to make it work for you to stay in medicine?

    2) How do you know it’s just 1%?

    Robin

  21. Steevo, I’m sorry you feel that way, but I certainly understand. Very much.
    I have two questions for you:

    1) What would it take to make it work for you to stay in medicine?

    2) How do you know it’s just 1%?

    Robin

  22. Ha! Nobody is ever gonna mistake me for a budget director! I am just a patient with insurance premiums going thru the roof. When I discovered that I had a rare endocrine disease 3 years ago, I opted to pay to “upgrade” from my HMO plan to the QPOS so that I could go out of network to utilize testing and treatment from more experienced doctors than were in-network.I am willing to pay the increase along with my regular monthly premiums of over $800. per month.
    But last month I had to cut out all out-of network benefits, as the premiums went up an additional $62. per week. If the doctors are complaining that they are not getting the $$, then what am I paying for? Who gets the cash?

  23. Ha! Nobody is ever gonna mistake me for a budget director! I am just a patient with insurance premiums going thru the roof. When I discovered that I had a rare endocrine disease 3 years ago, I opted to pay to “upgrade” from my HMO plan to the QPOS so that I could go out of network to utilize testing and treatment from more experienced doctors than were in-network.I am willing to pay the increase along with my regular monthly premiums of over $800. per month.
    But last month I had to cut out all out-of network benefits, as the premiums went up an additional $62. per week. If the doctors are complaining that they are not getting the $$, then what am I paying for? Who gets the cash?

  24. mottsapplesauce

    I hear ya Phil. My husband & I have chronic health issues. The insurance we carried for the last eight years decided to increase the premiums by 45%! That’s a huge increase! Yet, their fee schedules keep going down… The insurance CEO’s (private/commercial) make millions of dollars. I’m not saying they don’t have a right to make money, but they just keep on getting richer, while their policyholders are denied proper treatments (or reimbursements are delayed for several months).Seems evil doesn’t it? But, that’s the nature of the free-market. There’s very little accountability, even with government funding.

  25. mottsapplesauce

    I hear ya Phil. My husband & I have chronic health issues. The insurance we carried for the last eight years decided to increase the premiums by 45%! That’s a huge increase! Yet, their fee schedules keep going down… The insurance CEO’s (private/commercial) make millions of dollars. I’m not saying they don’t have a right to make money, but they just keep on getting richer, while their policyholders are denied proper treatments (or reimbursements are delayed for several months).Seems evil doesn’t it? But, that’s the nature of the free-market. There’s very little accountability, even with government funding.

  26. Q) Who always gets the money when insewerants premiums go up?
    A) The insewerers! They might return some of that increased money to the “service providers” (be they doctors, auto bodyshops, jobbing builders…), but it’s a racing certainty that a premium increase doesn’t result in a reduced profit for the insewerer!

  27. Q) Who always gets the money when insewerants premiums go up?
    A) The insewerers! They might return some of that increased money to the “service providers” (be they doctors, auto bodyshops, jobbing builders…), but it’s a racing certainty that a premium increase doesn’t result in a reduced profit for the insewerer!

  28. some dude named steevo

    Robin, I guess the 1% is just a guess, it could be a little higher but I am trying to stay positive. Those people posting on the NYT site remind of my patients when I was in the military…
    I don’t really have a choice, I can’t afford to start another career right now. I am just going to stop delivering babies, I don’t really deliver enough right now to pay for my malpractice insurance so it doesn’t make sense. I am also tired of getting called at all hours. My family is more important to me than my career, I don’t want to miss my kids growing up. Too bad though, there is nothing more magical than guiding a child into the world.

  29. some dude named steevo

    Robin, I guess the 1% is just a guess, it could be a little higher but I am trying to stay positive. Those people posting on the NYT site remind of my patients when I was in the military…
    I don’t really have a choice, I can’t afford to start another career right now. I am just going to stop delivering babies, I don’t really deliver enough right now to pay for my malpractice insurance so it doesn’t make sense. I am also tired of getting called at all hours. My family is more important to me than my career, I don’t want to miss my kids growing up. Too bad though, there is nothing more magical than guiding a child into the world.

  30. Mornin’, all…
    Steevo, I have a feeling you will be missed. If you have your own children (and it sounds like you do), you are so right about time with them, though. My mother warned me about how quickly they grow up, and she was so right. She also told me they weren’t mine to keep and that God had just loaned them to me. She’s a wise lady. I hope you find your niche and are happy in whatever you choose to do.

  31. Mornin’, all…
    Steevo, I have a feeling you will be missed. If you have your own children (and it sounds like you do), you are so right about time with them, though. My mother warned me about how quickly they grow up, and she was so right. She also told me they weren’t mine to keep and that God had just loaned them to me. She’s a wise lady. I hope you find your niche and are happy in whatever you choose to do.

  32. to Some dude named “Steevo”;
    Hey dude, look at this way. Life has it’s seasons, and you did it for awhile….time for change….and think how great it will feel not to have been up all night and drag around the next two days….you won’t be grouchy, you will have all your energy to be with your family, and you are darn well right about the wife and kiddies. Not only will you get to know your kids, but they will know you…..that is your legacy.

    And you might be surprised to find out how others have transitioned to other careers….I can give you several resources to give you ideas. Let me know, drop me an email gmlevinmd@gmail.com (semi retired ophthalmologist )at age 55…now 65…..

    Gary L

  33. to Some dude named “Steevo”;
    Hey dude, look at this way. Life has it’s seasons, and you did it for awhile….time for change….and think how great it will feel not to have been up all night and drag around the next two days….you won’t be grouchy, you will have all your energy to be with your family, and you are darn well right about the wife and kiddies. Not only will you get to know your kids, but they will know you…..that is your legacy.

    And you might be surprised to find out how others have transitioned to other careers….I can give you several resources to give you ideas. Let me know, drop me an email gmlevinmd@gmail.com (semi retired ophthalmologist )at age 55…now 65…..

    Gary L

  34. some dude named steevo

    Robin and Gary: I am not leaving medicine (I just took my recertification boards last month, so I have to get my money’s worth…). I am currently doing full spectrum family practice with obstetrics and I am just winding down on the obstetrics. There are several reasons I am ceasing deliveries, but the main reason is I have just lost my passion for delivering babies. I have no intention of quitting medicine altogether, but I have sort of given up hope that it will improve anytime soon. I have tried practicing in several different states over the past 10 years but it seems to be bad everywhere. I am just trying to accept the fact things will not be what I expected.

  35. some dude named steevo

    Robin and Gary: I am not leaving medicine (I just took my recertification boards last month, so I have to get my money’s worth…). I am currently doing full spectrum family practice with obstetrics and I am just winding down on the obstetrics. There are several reasons I am ceasing deliveries, but the main reason is I have just lost my passion for delivering babies. I have no intention of quitting medicine altogether, but I have sort of given up hope that it will improve anytime soon. I have tried practicing in several different states over the past 10 years but it seems to be bad everywhere. I am just trying to accept the fact things will not be what I expected.

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