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View Diary: In 'seismic shift,' primary care physicians creating revenue for hospitals (28 comments)

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  •  As a family doc, I'll believe it when I see it. (2+ / 0-)
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    FishOutofWater, Dallasdoc

    I've been in practice for over 25 years, and my income has fallen steadily for the past 10 years despite working longer hours. The hospitals that permit primary care docs to admit directly tend to be precisely the same ones that are closing their doors left and right: small rural hospitals and those in poor & under-served urban areas.

    Most big city academic hospitals and suburban hospitals in affluent areas earn the vast majority of their money from highly reimbursed procedures. They may be attributing more hospital income to the primary care docs by way of patients referred by us to the hospital, but this money rarely finds its way into the paychecks of said primary care docs. It flows to the institution and to the procedural subspecialists.

    "Accountable care organizations" in principle have a powerful incentive to bring more family docs into the system because we prevent expensive admissions and provide very low cost care. But these facts have been true for years, and primary care incomes have continued to fall relative to other specialties.

    The biggest hospital system in our region is courting us to joint their ACO which is in the formative stages. But its governance will be divided into four "equal" groups: the giant hospital administration, its highly paid subspecialty staff, representatives of other regional hospitals, and (bringing up the rear) community physicians, with primary care docs just one small slice of this one fourth share. This organization guarantees that (as always) primary care docs will always be outvoted by the bigger players.

    •  urban med centers make the money (0+ / 0-)

      Small and mid-sized hospitals aren't because they can't maximize return on investments in expensive equipment & infrastructure. The subspecialsts who do fancy procedures with fancy equipment make the big money. Perhaps the ACOs will change this for Medicare, but that will encourage urban hospitals to cherry pick the good insurance plans and try to minimize Medicare admissions.

      look for my eSci diary series Thursday evening.

      by FishOutofWater on Thu May 23, 2013 at 06:39:38 PM PDT

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    •  I don't blame you for your frustration (1+ / 0-)
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      My income as a primary care doc has gone up in the last decade, but that's probably because I moved from a community health center in the part of the country where docs get paid the least, to a multispecialty private group in a state with moderate physician incomes.  

      My group has recently sold itself to a much larger out-of-state group which has specialized in the sort of coordinated care CMS is pushing to three decades.  They're very good at it, with outstanding quality and patient satisfaction scores and much better than average costs.  They're a primary care group in their original very large market, but a multispecialty group in satellite entities they've bought into.  We're trying to leverage their expertise to introduce coordinated care concepts into our city, because they have shown it can lead to better and cheaper patient care.  That's important in our relatively poor state.

      We're going through rough start given the unwillingness of some of our larger payers to go along, since they own hospitals and see themselves losing money:  care is cheaper primarily because if you keep people healthier you can keep them out of the hospital, and use other resources like SNF's and ambulatory surgical centers for a lot of the care hospitals like to provide.  Our specialists are nervous, but they will do well as our capitated contract volume rises.  The incentives for them will move toward managing patients in a cost-effective way, rather than maximizing expensive procedures.  The difference from 1990's capitated care is that our EMR systems allow us to do it right, and to include increasing quality measures as a requirement for success.

      If you want to cut Social Security, you're not a real Democrat.

      by Dallasdoc on Thu May 23, 2013 at 06:52:11 PM PDT

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      •  It's all about where the money goes. (1+ / 0-)
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        Under capitation or other global payment arrangements, there may undoubtedly be huge cost savings compared to fee-for-service, with improved quality as well.

        But where do the savings go? I've heard lots of talk about 'gain-sharing', but the details of the contracts are enormously important and often exceedingly opaque to non-financial types. Tiny sub-clauses can make all the difference between significant pay increases for primary care docs, and ruinous declines.

        The Accountable Care Act mandates that these agreements place the physicians at financial risk, as a supposed anti-trust measure. (It's okay for 75% of mail order prescriptions to be managed by two companies in America, but doctors are forbidden from working cooperatively. Go figure.) This means we have to put in a big chunk of money out of pocket up front, and/or place a substantial part of our pay at risk. That's a very scary demand considering we have gotten screwed over and over by big regional groups, insurers and employers.

        Given 25 years of consistently negative experience, I am very skeptical that we will really see a financial gain from the ACA in primary care, whatever the other benefits of the law. Mind you, I still strongly support ACA because our patients will benefit and there are provisions to restrict the insurers' worst abuses.

        •  That's pretty simple (0+ / 0-)

          If you're working for someone, they get the money.  I'm much more comfortable in a physician-run organization, and feel less likely to get completely screwed by the corporate overlords that way.

          Regulation of providers is getting ridiculous, especially with the new HIPAA regulations.  I take your point about the near-complete lack of regulation of other big actors in health care, and can only hope they get theirs soon.

          If you want to cut Social Security, you're not a real Democrat.

          by Dallasdoc on Fri May 24, 2013 at 06:43:57 AM PDT

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