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Doctors, especially the primary care doctors who could help control costs, are opting out of Medicare because Medicare doesn't pay them enough.  Paying those primary care doctors for their expertise and time spent following up with patients, reassuring the patients, and 'directing traffic' by referring them to the most appropriate consultants and specialists, could go a long way toward reversing this trend.  Currently, since most such follow-up and managing of referrals is done over the phone, Medicare refuses to pay for it.  Bringing primary care doctors back on board in an effort to control overall costs would likely save money for Medicare.  One way of doing this would be to pay doctors for time they and their office staff spend on the phone with patients and with specialists and insurance companies arranging consults.  Another way would be to put part of a primary care doctor's pay from Medicare on a capitated basis.  
Another potential area for savings is smoothing the transition from hospital back home, especially for patients who will not be followed as outpatients by the same doctor who admitted them to the hospital.
Since the free market hasn't come up with a way to make health care available and affordable, the government needs to step in.

President Obama has put the American health care affordability crisis near the top of his agenda, and for good reason.  I quite agree that the problem requires a government imposed solution.  Leaving it in the hands of the 'free' market is exactly what has gotten us into this mess.
One well appreciated problem in the American health care system is the shortage of primary care doctors.  This article in today's New York Times,
"Doctors Are Opting Out of Medicare,"
is a nice summary of the problem.

If Congress wants to alleviate this problem, I suggest Medicare start paying primary care doctors better.  What's more, paying them better can actually SAVE money in the long run, if the better pay comes with a reasonable amount of responsibility for holding costs down.

Between Medicare and Medicaid, Federal programs already pay for a lot of the primary care in the United States.  But the pay is so poor that doctors are leaving the field for greener pastures.  Most primary care is done by Family Practitioners, Pediatricians, Obstetricians and Gynecologists for younger ladies, and Internists.  (Internists are specialists in internal medicine; NOT trainees in their first year out of medical school -- those are interns.)  

I'm an internist.  Yesterday I took my tax records to my accountant so he could do my income tax return.  As I was leaving, I thought to ask him if he knew any doctors looking for a place to practice.  I own my office building.  For years it had three doctors working there, but now I'm the only one left, and I haven't found anyone who seems interested in starting up in mostly primary care.  I could use a partner or tenant to share the expense of maintaining the building.  My accountant told me he knows a couple of doctors who have practices like mine, but one is ill and considering retirement, and the other recently closed his office to become a hospitalist.  

A hospitalist is a doctor who specializes by taking care of patients only while they're in the hospital.  That seems to save some money PER HOSPITALIZATION, probably by getting the patients out a little sooner.  It may not save that much money, if any, for a given group of patients over the long term.  That's because transferring the patient from the care of a hospitalist to a primary care doctor who follows outpatients probably creates more opportunity for things to 'fall through the cracks'.  If something important 'falls through the cracks' during that transition, the patient may have to go back to the hospital.  Any system that measures efficiency solely in terms of cost per hospitalization won't pick up on the inefficiency of preventable rehospitalization.  Medicare's system of paying hospitals a flat rate for the illness treated makes hospitals focus on efficiency PER HOSPITALIZATION.  Most private insurance companies follow Medicare's lead and do the same.  This story from the Washington Post,
"1 in 5 Medicare patients readmitted within month"
covers a study published in today's New England Journal of Medicine on exactly this problem.  Perhaps Medicare should pay the primary care doctors who'll be taking over the patient's care to make one hospital visit soon before the patient is discharged, or maybe enough to make it worthwhile to make a house call (remember those?) soon after the patient gets home.  Routinely putting patients on a home health nursing service for a few weeks at least after hospital discharge would likely help, too.

Years ago, I practiced more as a younger internal medicine consultant for some older primary care doctors.  I remember one old General Practitioner, "Dr. R," in particular (back then, General Practitioner or GP the term for what we now call Family Practitioners).  Dr. R. seemed to spend a lot of his time just consulting one or another specialist on each of his patients.  I once mentioned this to another specialist, Dr. S, whom Dr. R. would also consult.  I said something like, "Dr. R. seems to be mostly directing traffic," perhaps with a touch of derision in my voice and mind.  Then Dr. S taught me something I hope I'll never forget, with his reply, "Yes, and he's VERY GOOD at it.  His patients seem to get excellent care."  Dr. S. was right.  Knowing whom to consult, and sending the patient to that specialist or calling him/her in, especially with a good introduction in the form of a brief history of what's going on with the patient, pointing the consultant toward the problem that needs to be addressed, is a very valuable talent.  Dr. R's patients didn't bounce around from one specialist to another, until they stumbled on the right one, meanwhile running up a huge bill for Medicare.  That often happens when patients self-refer and sometimes happens when an inexperienced primary doctor is doing the consulting.  I'm confident Dr. R. didn't just save his patients time, pain, and uncertainty; he also saved Medicare a lot of money.  

Talent for 'directing patient traffic' efficiently would probably be very hard to measure, but I'm optimistic most primary care doctors would like to be good at it, and would put some time, effort, and thought into getting better at it if they felt Medicare paid them enough.  It would probably work even better if Medicare added a bit of recognition and some bonus money for doctors who seemed to be doing well at it, even if the measure of who was doing well was a bit arbitrary and sometimes off target.  

In addition to my private practice, in the last couple of years I've gotten some experience with a health care system that is, within limits, a capitated model: hospice medicine.  When a Medicare patient goes on hospice, the hospice gets paid a flat rate, currently about $120 a day in my part of the country, which is supposed to cover ALL of the patient's needs for his or her terminal diagnosis.  Covering ALL of a patient's needs, even for just one diagnosis, puts the hospice in the position of being an insurance company, but there are several 'outs' that make that responsibility manageable.  

If a patient needs more intensive care for control of pain or some other symptom, he can go on 'continuous care' at home with a nurse's aide there 24-7 (though the need is reevaluated every 8 hours so it's not likely to get to the "7" as in continued for a week.)  The hospice gets paid more when a patient is on continuous care (a figure of about $350 a day comes to mind and may be accurate), though they usually pay the entire daily payment in overtime for extra nursing care.  Another 'out' is "general inpatient care" which can be done at a skilled nursing home or at the hospice's own inpatient unit if it has one.  Again, the hospice is paid more for 'GIP' days (something in the range of $550-600 a day, I think), but to accept GIP patients the nursing home usually gets paid the entire per diem Medicare allows; the nursing home does most of the work but the hospice still sends a nurse to visit once a day to keep in touch with what's happening to the patient.  Also, there's a limit: a hospice can't bill more than 20% of its total patient days as inpatient days.  

A third 'out' is that the patient can 'revoke' -- come off hospice care and revert to regular Medicare -- at any time.  If a patient decides he wants to try some aggressive (read expensive) new treatment that the hospice doesn't cover, the patient can revoke.  He's eligible to be readmitted to hospice at any time unless the treatment helps him enough that he's no longer terminal.  (Medicare's current definition of 'terminal' is that the patient's condition suggests a life expectancy of 6 months or less.)  A fourth 'out' (and probably the biggest one for providing insurance for a hospice patient) is, to put it bluntly, that the patient is expected to die.  There's an obvious potential for abuse of that 'out', but so far I don't think that's been much of a problem.  One deterrent is that the nurses and aides get pretty attached to the patients and their families.  Those nurses want to be able to look at themselves in the mirror the week after a patient has died.  Actually, it's often nurses who do the enforcing and the drawing of lines in the sand on medical ethics, and not just in hospice.  

For a non-hospice patient, none of those 'outs' is available.  An HMO can take capitated payments -- so much a year for each person covered -- as long as its patient group is big enough to balance the few expensive sick patients with a lot of healthy people.  A primary care doctor in private practice, or even a moderate sized group of doctors, can't afford to take on the risk.  One patient with a curable but expensively curable disease could bankrupt them.  A market solution to the problem is imaginable, but it doesn't exist:  If insurance companies offered some sort of reinsurance policy that primary care doctors could buy, that would cover the cost of treating those 'expensively curable' diseases, the primary care doctors could accept capitated patients.  BUT the reinsurance would need to kick in before the costs for a given patient got ruinous, and would need to be cheap enough that it wouldn't sop up most or all of the capitated payment.  If any such reinsurance is available, I haven't heard of it.  Insurance companies have gone into the business of insuring against some hard to measure risks, but so far is has been mostly the risks of subprime mortgages defaulting.  Seeing how that worked out, I doubt any insurance company is soon going to look for ways to branch out into the business of insuring against the risk of a cluster of patients with expensively treatable diseases.

So, since the free market hasn't come up with a solution, and the unsolved problem is a major drag on the economy, the government needs to step in.  We need a government health insurance program that pays doctors to hold down costs, but without severe penalties to the doctors for those expensively curable patients on whom cost control just doesn't work.  The system also needs to avoid or at least blunt any perverse incentives -- for example, any incentive to let an expensive but curable patient just go ahead and die to save money.  Any such system would likely involve paying primary care doctors more, not less.  My pet idea is for Medicare to pay primary physicians partly on a capitated basis:  Encourage every Medicare beneficiary to sign up with a primary care doctor, and pay the doctor a few dollars a month for each patient, as long as the patient stays out of the hospital.  If what Medicare pays for a primary care doctor's usual services, like office visits, weren't so low I'd suggest reducing the scale somewhat to finance the capitated patients.  As it is, with doctors bailing out of primary care for Medicare patients, I think the capitated payments should simply be added to the current pay scale, as an extra incentive.

How bad is it for primary care doctors treating Medicare patients now?  Pretty bad, as that New York Times article made clear.  One former 'profit center' (which could also be called a dirty little secret) that helped primary care doctors get rich/stay in business was the markup on lab tests.  Some private insurance plans still let a doctor bill directly for blood tests done on blood samples the doctor draws but sends out to a 'reference lab'.  Medicare stopped doing that years ago.  On lab we send out from my office, all Medicare pays is a fee for drawing and handling the sample.  They pay $3.00.   Last week I had a patient on whom I ordered quite a number of tests, including some that I don't commonly order.  The lab technician needed fifteen minutes just to fill out the paperwork, and that was after he'd drawn the blood samples.  Then, over the next three days, the patient telephoned me twice to ask about the results.  I discussed them with her over the phone.  Most of the tests were normal -- the only thing we found was a mild anemia likely due to a marked iron deficiency -- but the phone calls took me a good 15 minutes.  If there had been something else abnormal, I probably would have referred the patient to a specialist, which would have taken more telephone time -- especially if I did it RIGHT, speaking to the consulting doctor myself, which makes his job simpler, more effective, and perhaps cheaper.  

Last week I had the impression that Medicare had started paying for telephone time.  My office manager noticed that there are billing codes for short, medium, and long telephone calls, so I carefully kept track of my calls for a week.  It added up to a good bit of time.  Then, this week, my office manager checked with Medicare on whether they would pay for those calls.  Guess what -- they won't.  The billing codes exist, but Medicare doesn't pay anything if you submit bills for those calls.  My office manager asked sarcastically if I was just supposed to hang up on those phone calls, or tell the patients they had to come back to my office to discuss things.  The lady from Medicare said yes.

I can't resist making a comparison to another profession:  Try making a phone call to a lawyer with a follow-up question about something you've recently consulted him on.  For anything more substantial than, "No, we're still waiting to hear back on that," you can expect the meter to start running.  How fast?  A minimum of $200 an hour, for any lawyer who's been in practice a few years.  (I seem to recall that Kenneth Starr proudly quoted his usual fee at $395 an hour, and that was several years ago.)  If your lawyer is good enough to keep track of time by tenths of an hour, a quick phone call could be as low as $20.  Some lawyers go by fourths of an hour, so the minimum, at $200 an hour, would be $50.  And I can't resist pointing out that back in college, a lot of the pre-law students are former pre-meds who couldn't pass organic chemistry.  

Perhaps it's a conceit, but I happen to think my phone calls about patient care are as valuable as the ones my lawyer bills me for.  One way or another, Medicare should pay me for them.

Originally posted to david78209 on Thu Apr 02, 2009 at 08:04 PM PDT.

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Comment Preferences

  •  Tip jar (20+ / 0-)


    We're all pretty strange one way or another; some of us just hide it better. "Normal" is a dryer setting.

    by david78209 on Thu Apr 02, 2009 at 08:05:00 PM PDT

  •  Great diary David (9+ / 0-)

    You have a rich story to tell.  Being a primary care internist too, I certainly agree that better relative reimbursement for primary care providers is vital to restoring access to care for all Americans.  Not sure we all need more money (except in certain parts of the country where we're less well-paid), but I would favor cutting some of the exorbitant fees paid to specialists.  

    Primary care docs can certainly help cut costs.  Far too many of us prescribe expensive branded drugs rather than generics, though in my experience specialists are more commonly guilty of this.  A lot of MRI's are ordered unnecessarily for conditions a good neurologic exam or a round of physical therapy would be more suited to.  

    Incentivizing us to look at outcomes would save money and improve care too.  Getting diabetics under better control, persuading smokers to quit, and finding all the many many undiagnosed cases of sleep apnea would save lots of money while improving our patients' health dramatically.

    We all have a part to play in improving health care.  I fear, though, that those who call the shots in "reform" will not be those who have the knowledge you and I do about what would really help.

    Dear Republicans: You can't repeat a lie enough to make it true.

    by Dallasdoc on Thu Apr 02, 2009 at 08:15:35 PM PDT

    •  Maybe they'll listen to Dr. Howard Dean (3+ / 0-)
      Recommended by:
      Dallasdoc, Pris from LA, FarWestGirl

      My favorite internist -- who also quit practice to go into something else, didn't he?

      We're all pretty strange one way or another; some of us just hide it better. "Normal" is a dryer setting.

      by david78209 on Thu Apr 02, 2009 at 08:58:17 PM PDT

      [ Parent ]

    •  I believe MRI scans (3+ / 0-)
      Recommended by:
      Dallasdoc, david78209, FarWestGirl

      cost about $98 each in Japan.

      In Denver, where I live, if you get an MRI of your neck region it's $1,200, and the doctor we visited in Japan says he gets $98 for an MRI. So how do you do that?

      Well, in 2002 the government says that the MRIs, we are paying too much, so in order to be within the total budget, we will cut them by 35 percent.

      So the health ministry set a low price, the MRI makers make cheaper machines to help the doctors meet that price, and now Japan is exporting these around the world?

      Right. ... This is a situation where the market does work in health care.

  •  Thanks for your perspective. (4+ / 0-)
    Recommended by:
    david78209, Pris from LA, Katie71, DParker

    I always find it interesting to hear from medical professionals themselves about the state of US health care.

    Could I ask a vaguely related question?

    I have heard (both in the media and from nurses whom I know) that doctors' ordering excessive tests is a significant contributing factor to rising health care costs.  The reason often cited is fear among doctors of being sued for malpractice.  Nurse acquaintances have told me stories, for instance, of children who pretty obviously had run-of-the-mill cases of flu or tummy aches who were put through whole batteries of tests to rule out extremely low-probability diagnoses.

    Of course, I understand that if even one diagnosis of a really serious condition is missed, that's a terrible thing.  But still, life is full of compromises.

    Is this a real problem?  Is it a significant part of the reason health care costs in this country are so high?

    •  It's a problem, but... (3+ / 0-)
      Recommended by:
      Pris from LA, FarWestGirl, HappyTexan

      Though it's hard to measure, I think it's down on the list, and probably doesn't cause more than 10-20% of the 'excess' cost that could be reduced.  
      For one thing, if those 'CYA' tests get frequent enough, they usually should get a 'volume discount' and become cheap.

      We're all pretty strange one way or another; some of us just hide it better. "Normal" is a dryer setting.

      by david78209 on Thu Apr 02, 2009 at 09:02:21 PM PDT

      [ Parent ]

      •  That's the thing... (1+ / 0-)
        Recommended by:

        The higher costs of the tests cause the insurance companies to squirm and try to find a way to stop paying out as much.

        So they decide to just deny coverage to someone... that $25,000 bill gets dropped in that poor person's lap, and of course how many have that in cash to pay?

        So, they don't pay, and then the hospital has to raise costs for everyone else for everything, to make up for those shortfalls...

        And it's this insane vicious cycle that keeps feeding on itself.

        Doctors can't just refuse to run diagnostics like that period, to do so potentially opens them up to malpractice.

        For what it's worth, I intend to try to pay for my own medical needs out of pocket with cash, either up front or immediately upon service rendered. If someone else wants to do that, you might help by giving them whatever discount you can afford just for all the trouble they've saved you... that is, if you have your own practice. I've only seen a few of your comments, didn't notice you mentioning whether or not you do.

        •  I call it a "real money discount" (1+ / 0-)
          Recommended by:

          for anyone who pays his own bill.  Heck, most private insurance companies have followed Medicare's lead, and have limits on what they'll pay for a given procedure.  If I've joined a PPO, that involves agreeing to the fee schedule.  Usually it's simply quoted as, say, 110% or 103% of what Medicare pays.

          We're all pretty strange one way or another; some of us just hide it better. "Normal" is a dryer setting.

          by david78209 on Thu Apr 02, 2009 at 10:51:33 PM PDT

          [ Parent ]

  •  Can't complain (5+ / 0-)

    about my primary care doctor.  He was wise enough to know when it was time to send me elsewhere.  He's still more than willing to keep up with my prescriptions prescribed by the specialists.  I am grateful, yet I still see the specialist because if I don't, I stand to lose " patient of" status and could have a difficult time getting back in to see him when I need to.  Frankly, I  "need to" on at least a yearly basis as my primary care doctor has little idea as to how to treat me.  

  •  My PCP won't take on new patients (4+ / 0-)

    who have Medicare, but will keep patients who have gone from traditional insurance to medicare.  

    From my own perspective, I have two specialists I see regularly and a PCP I see only sporadically.  My experience is that my wait time for the specialists is significantly shorter than it is for my PCP.  Although I don't know this, my supposition is that the PCP has to see a lot more patients each day because of the pay discrepancy.  It's frustrating as a patient to wait that long to just be hustled in and out so quickly and I can't imagine the doctor is too happy with the situation either.

  •  The answer is simple... (1+ / 0-)
    Recommended by:
    Pris from LA

    We need laws to compel these doctors to accept Medicare. If they refuse, they should lose their license.

    •  Does that run afoul of the Thirteenth Amendment? (2+ / 0-)
      Recommended by:
      TiaRachel, FarWestGirl

      You know, the one that bans involuntary servitude?  If not, it certainly seems to deprive a group of their preferred way of earning a living for refusing to go along.  

      Are a doctor's education and time subject to eminent domain?  I'd like to see my medical education considered "intellectual property" and protected with as much zeal as Congress has lately shown for Disney's copyrights on Mickey Mouse.

      We're all pretty strange one way or another; some of us just hide it better. "Normal" is a dryer setting.

      by david78209 on Thu Apr 02, 2009 at 09:12:48 PM PDT

      [ Parent ]

      •  Hey, you could be a lawyer... (1+ / 0-)
        Recommended by:

        Most Bar Associations require a certain percentage of pro bono publico work to keep in good standing. It's not the government saying this, it's the professional organization requiring it.

        Everyone needs to give something in these hard times. And to him who is given much, much is required. I think that requiring doctors to accept medicare and medicaid is a small price to pay for being in a very lucrative business.

        Or you could just hang up your medical practice and work for an insurance company denying claims all day. I hear that's really lucrative work. If you have no conscience.

      •  Dude, I was being sarcastic. (1+ / 0-)
        Recommended by:

        Yes, it amounts to slavery. I'm suspect that it will happen eventually though, and that the bureaucrats responsible for making sure you're not earning too much will be paid twice as much as you are.

        Scary though, there are people who thought I was serious, it would seem.

    •  The reason isn't because they're greedy (3+ / 0-)
      Recommended by:
      TiaRachel, david78209, FarWestGirl

      or selfish, or don't want to help the people most in need, its because the amount medicare pays primary care physicians directly jeopardizes their ability to keep the office's lights on and doors open.

      What if half of the customers where you work paid roughly 17 cents on the dollar for your product? Not calling health care a "product" per se, but if they aren't able to operate profitably, then there's no health care for anyone.

      The biggest overhead cost isn't even "outrageous" pay of doctors. It's doctors' insurance policies against malpractice. It all comes back to the insurance companies.

      •  I know. (2+ / 0-)
        Recommended by:
        david78209, PsychicToaster

        It was sarcasm. I was curious if there were any who thought as such, and it seems there are a few.

        Whatever is the cause of the high cost of healthcare, it's not because GPs are driving gold-plated Ferraris.

        In fact, I think I make more than many doctors do their first few years, which is scary all by itself... I'm nothing special.

        What if half of the customers where you work paid roughly 17 cents on the dollar for your product? Not calling health care a "product" per se, but if they aren't able to operate profitably, then there's no health care for anyone.

        It is a product. There's nothing shameful in calling it that... hell, it's more than a product, it's a good, wholesome product.

        It's doctors' insurance policies against malpractice.

        I think this is part of the problem, but not the whole issue. Even if it is fixed, I don't think the bottom line would change much... it's a mix of several different issues.

        If health insurance doesn't cover a procedure, the patient doesn't toss $25,000 at the lady in the billing department... it just goes unpaid. Hospitals and doctors then have to raise the price for everyone else, to make up for whatever the percentage is for cases like that, and this has to contribue to it all.

    •  They shouldn't lose their license, (0+ / 0-)

      only their prescription pads.

  •  They get paid very well (0+ / 0-)

    My aunt's last visit was $91.

    I think I figured out that it works out to be about $200/hour.

    It's the large office staff that burns through the money. Three people at $20/hour each is $60/hour.

  •  One usually goes to a hospital outpatient lab (0+ / 0-)

    for tests.

    I was there Tuesday with my aunt.

  •  Hospitalists exist (0+ / 0-)

    because doctors that have hospital privileges are expected to pull ER duty which can mean nights and weekends.

    My aunt's doctor doesn't see his patients in any hospital.

    He likes his four day 8-5 workweek.

  •  A lawyer's client (0+ / 0-)

    won't die from a lawyer-prescribed drug.

    I see potassium on my aunt's counter.

    Since potassium can kill, the doctor's office gets a call.

  •  We need to increase the number of doctors. (1+ / 0-)
    Recommended by:

    Admit more students to med schools, now.

    "The dirty little secret,,,is that every republican politician wants Obama to fail,," rush limbaugh

    by irate on Fri Apr 03, 2009 at 05:15:38 AM PDT

    •  But they'll all become specialists (0+ / 0-)

      if being one continues to pay so much better than being a primary care doc.

      On the other hand, if primary care paid better, I think a lot of docs who do mostly consulting as specialists would go into (or go back into) primary care.

      We're all pretty strange one way or another; some of us just hide it better. "Normal" is a dryer setting.

      by david78209 on Fri Apr 03, 2009 at 06:27:42 AM PDT

      [ Parent ]

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