Absence of Primary Care Drs.

[SteveL]

Our local PBS station broadcast the following show on Jan. 2:
Sound Focus

It is well worth listening to. Presently, of the 700 Primary Care Phys. in Alaska, none will accept new Medicare/Medicaid patients. People in Mass. are having a very difficult problem finding a Primary Care Dr. as well.

[Leonidas]

Nephew-in-law (brother-in-law's son-in-law) has a business that tries to find new sources of revenue for doctor's (clinical research projects, etc.) He also runs business operations for two groups of specialists. Smart guy, tried but failed to get into medical school, and we were talking the other night about health care reform in the US. He said the average PCP in the Houston area takes home about $150K a year (specialists like those he works with have profits above half a mil). Considering the hours they work, the liability they face, and the initial investment at the start of their careers, I don't know why anyone would want to be a PCP for 150 grand a year.

Edit to add: It seems to me that career choices are based on financial and personal reasons. I'm not sure that becoming rich should be the reason why someone would want to become a doctor, but I do believe that the money should be adequate to attract smart, motivated folks who have a strong desire to help people. And the money has to be good enough to retain people in vital medical roles. But money, as in seeking more of it, can be a negative as well. Part of the problem with healthcare costs in this country has to be the result of the involvement of too many people motivated solely by maximizing profits.

[youbet]

Quote:

Originally Posted by Leonidas I do believe that the money should be adequate to attract smart, motivated folks who have a strong desire to help people.

That's what salary levels should be about for all professions. Salaries increase to attract more qualified people into the field until equilibrium is reached. Sadly, artificial restrictions such as unions, associations, pay restrictions (insurance companies in the case of doctors), barriers to entry such as limited training availability, high training costs, etc., keep the supply and demand system from working.

I'd like to see widely available govt schlorships available for medical school, nursing training and medical technician training.

[Marshac]

I pop into ER land to see how things are going a lot less frequently now that i've given up on FIRE, but to share my two cents on this topic...

For me personally, I would never go into GP simply because I don't want to deal with insurance companies, malpractice insurance (and lawsuits!), etc. Some of the Drs in the ER I have talked to have mentioned how much their insurance costs are- one of them has told me that he has a friend that's a computer programmer and he takes home more money per year once you back out insurance costs (since i'm coming from the IT realm, this statement didn't supriuse me). Is it any wonder people are deciding NOT to become doctors when they can make more money with less work and less schooling (and less debt)?

I'll probably make a career as an Army Dr simply because I don't want to deal with all of this crap.

[Martha]

Marshac, nice to see you. Army doctor sounds fine, but maybe just a different load of crap.

[Rich_by_the_Bay]

Quote:

Originally Posted by Martha Army doctor sounds fine, but maybe just a different load of crap.

... with a COLA'd pension.


But on the topic of primary care, there is a movement within medicine called the "medical home." It's basically "a team-based model of care led by a personal physician who provides continuous and coordinated care throughout a patient's lifetime to maximize health outcomes. The PCMH practice is responsible for providing for all of a patient’s health care needs or appropriately arranging care with other qualified professionals. This includes the provision of preventive services, treatment of acute and chronic illness, and assistance with end-of-life issues. It is a model of practice in which a team of health professionals, coordinated by a personal physician, works collaboratively to provide high levels of care, access and communication, care coordination and integration, and care quality and safety."

There is a lot of lobbying to improve reimbursement for these services which entail a broad set of responsibilities, a unique knowledge base, strong listening skills and psychosocial awareness, etc. I support it.

[Marshac]

Quote:

Originally Posted by Martha Marshac, nice to see you. Army doctor sounds fine, but maybe just a different load of crap.

This is true... one of the docs in the ER was a physician in the navy for 10 years, and he really enjoyed his dual role as a physician and an officer, although some of his colleagues in the navy hated it.

The deal with the Army is-
1- 100% of medical school expenses covered
2- $1800/mo tax free stipend while in med school
3- Residency pay is double if I chose to perform my residency in an army hospital (although I can perform my residency anywhere- no obligation to the amry here)

What they get-
1- One year of service for every year i'm on their dime

The deal is too good to pass up it seems. I don't want to derail this thread, but if there are any doctors here that would like to PM me a few pointers on how to ask for letters of recommendation for med school, I would really appreciate it.


My wife is a floor RN at a local hospital, so she sees a lot of ortho/neuro post-op... and consequently a lot of very old people. Many times I find myself shaking my head as she tells me about 85 year old patients with end-stage dementia undergoing total hip replacements. It's really debatable whether the quality of the patient's life has been improved- especially since they may not even understand what's happening to them anymore. I think the real debate that's lacking in this country isn't how we're going to pay for medical care, but what's a realistic level of care for everyone. Clearly the model 'sparing no expense' to prolong the life of someone who is already quite old (and mentally no longer here) fails when applied to everyone in a rapidly aging nation. Is the goal of medicine to delay death as long as possible, or to provide the best care for patients? Are the two mutually exclusive? I'm not sure they are.

Also- my observations from the ER I volunteer in- I see low-income patients with chronic conditions (like asthma) that have been going untreated come in because their condition has suddenly become a lot more acute. Since the ER must provide treatment regardless of their ability to pay, this is where they go.... so now their chronic condion that would have cost $20 monthly to treat suddenly necessitates a costly visit to the ER... to me this system seems totaly flawed..... It also seems to annoy the ER docs since they get stuck doing the work that a GP should be doing for the patients.

[Corporateburnout]

Quote:

Originally Posted by SteveL Our local PBS station broadcast the following show on Jan. 2: Sound Focus It is well worth listening to. Presently, of the 700 Primary Care Phys. in Alaska, none will accept new Medicare/Medicaid patients. People in Mass. are having a very difficult problem finding a Primary Care Dr. as well.

I live in MA and our PCP decided back in October to leave his practice after he suffered a mild stroke to teach at Brown. He was replaced by a part time physician that does not belong to my insurance plan's network.

We are having a tough time finding a PCP that will accept new patients.

[FIRE'd@51]

Quote:

Originally Posted by SteveL Our local PBS station broadcast the following show on Jan. 2: Sound Focus It is well worth listening to. Presently, of the 700 Primary Care Phys. in Alaska, none will accept new Medicare/Medicaid patients. People in Mass. are having a very difficult problem finding a Primary Care Dr. as well.

While this certainly isn't a good thing, IMHO, one doesn't really need a PCP. The expensive care will most likely be handled by a specialist, and I haven't heard of a whole lot of specialists refusing Medicare patients. Most orthopaedic surgeons, urologists, cardiologists, etc. wouldn't have much of a business if they didn't take Medicare patients. Worst case is you pay the PCP out-of-pocket for minor illnesses and to get a referral to a specialist if you need one.

[Rich_by_the_Bay]

Quote:

Originally Posted by FIRE'd@51 While this certainly isn't a good thing, IMHO, one doesn't really need a PCP. The expensive care will most likely be handled by a specialist, and I haven't heard of a whole lot of specialists refusing Medicare patients. Most orthopaedic surgeons, urologists, cardiologists, etc. wouldn't have much of a business if they didn't take Medicare patients. Worst case is you pay the PCP out-of-pocket for minor illnesses and to get a referral to a specialist if you need one.

Ah, but only some 10-20% of patients seeing a PCP for a new problem end up with a referral to a specialist. And the initial care rendered by the PCP will be much less aggressive than that of a specialist. Consultants must, somewhat necessarily, do definitive, "buck stops here" evaluations much of the time.

Come to your internist with a headache and he or she will check for signs of serious causes; if there are none, maybe some basic tests, a bit of reassurance and careful follow-up with some symptomatic measures. If it seems to be a migraine, no problem, specific treatment can be given. Recheck in 2 weeks and if all is well, that's that. If things are not improving, maybe then consider a referral (maybe 10% of the time).

OTOH, if you skip the PCP and refer yourself to a neurologist, there is a much greater likelhood you will get an MRI or CT scan, receive expensive blood work for vanishingly improbable (although possible) causes.

I may be exaggerating a bit to make my point, but it's like that. PCPs are trained and experienced in evaluating the undifferentiated patient where the various diseases are present with the same probability of their incidence in the general public. They do things stepwise and probabilistically. Specialists see a subpopulation already seen and initially evaluated by a PCP with little yield; because the chance of rarer diseases is higher and the liability for "missing something" is greater, they take a more exhaustive (and expensive) approach.

Not saying one is right and the other wrong - just that each does what is appropriate for the population they are trained to see. Primary care by a team of subspecialists is arguably the worst of all worlds: expensive, excessive, aggressive and filled with incidental findings, and likely to overlook preventive measures, psychophysiologic issues, etc.

My first stop for care is my internist for almost any problem.

[FIRE'd@51]

Quote:

Originally Posted by Rich_in_Tampa Ah, but only some 10-20% of patients seeing a PCP for a new problem end up with a referral to a specialist. And the initial care rendered by the PCP will be much less aggressive than that of a specialist. Consultants must, somewhat necessarily, do definitive, "buck stops here" evaluations much of the time. Come to your internist with a headache and he or she will check for signs of serious causes; if there are none, maybe some basic tests, a bit of reassurance and careful follow-up with some symptomatic measures. If it seems to be a migraine, no problem, specific treatment can be given. Recheck in 2 weeks and if all is well, that's that. If things are not improving, maybe then consider a referral (maybe 10% of the time). OTOH, if you skip the PCP and refer yourself to a neurologist, there is a much greater likelhood you will get an MRI or CT scan, receive expensive blood work for vanishingly improbable (although possible) causes. I may be exaggerating a bit to make my point, but it's like that. PCPs are trained and experienced in evaluating the undifferentiated patient where the various diseases are present with the same probability of their incidence in the general public. They do things stepwise and probabilistically. Specialists see a subpopulation already seen and initially evaluated by a PCP with little yield; because the chance of rarer diseases is higher and the liability for "missing something" is greater, they take a more exhaustive (and expensive) approach. Not saying one is right and the other wrong - just that each does what is appropriate for the population they are trained to see. Primary care by a team of subspecialists is arguably the worst of all worlds: expensive, excessive, aggressive and filled with incidental findings, and likely to overlook preventive measures, psychophysiologic issues, etc. My first stop for care is my internist for almost any problem.

R-I-T

Thank you for that. I totally agree with everything you say about the advisability and importance of initially going to a PCP and certainly didn't mean to downplay the role of the PCP. However, we are talking about instances in which the PCP supposedly refuses to take new (Medicare) patients, leaving some patients without access to a PCP.

I think you pointed out in another thread that what this really means is that the PCP doesn't accept Medicare assignment. So long as the PCP is accepting new patients (and some aren't - Medicare or otherwise) but not Medicare assignment, can't I go to the PCP, pay him his normal fee, and submit the bill to Medicare myself, thereby recouping whatever Medicare would pay for that service, and pay the rest out-of-pocket (much the same way as going to an out-of-network provider with regular insurance). I don't see how a PCP could legally refuse to see some Medicare patients (i.e. the new ones) and treat other established ones, unless he were taking no new patients, period. Either he accepts Medicare assignment for all patients, or he doesn't. I think I am paraphrasing what you pointed out in another thread. Please correct me if I am wrong.

[Rich_by_the_Bay]

Quote:

Originally Posted by FIRE'd@51 can't I go to the PCP, pay him his normal fee, and submit the bill to Medicare myself, thereby recouping whatever Medicare would pay for that service, and pay the rest out-of-pocket (much the same way as going to an out-of-network provider with regular insurance). I don't see how a PCP could legally refuse to see some Medicare patients (i.e. the new ones) and treat other established ones, unless he were taking no new patients, period. Either he accepts Medicare assignment for all patients, or he doesn't. I think I am paraphrasing what you pointed out in another thread. Please correct me if I am wrong.

I think that's correct and is commonly done. But it's a treacherous road for the PCP. I recall that he or she must treat all medicare patients the same (i.e. accepting v. not accepting assignment) so established patients on assignment must now go off assignment -- not a good move in many ways. To avoid that altogether, many simply stop taking new medicare patients and hopefully allow their practices to fill with higher-paying insurers.

It's a mess and a terrible distraction from patient care - one of the reasons I left private practice 15 years ago. I ended up taking assignment on all, but when such patients would make an appt for a blood pressure follow-up and would unexpectedly start reading me their list of 3 or 4 other nonurgent issues, rather than indulge them for another 15 minutes I found myself saying things like, "I know these are important questions for you, but we didn't leave enough time today to give them the attention they deserve. Why don't you schedule a follow-up at your convenience and we'll look into them further." You can see the problem.

Thanks for the expanded points on your OP - I think we agree.

[JPatrick]

Quote:

Originally Posted by Marshac This is true... one of the docs in the ER was a physician in the navy for 10 years, and he really enjoyed his dual role as a physician and an officer, although some of his colleagues in the navy hated it. The deal with the Army is- 1- 100% of medical school expenses covered 2- $1800/mo tax free stipend while in med school 3- Residency pay is double if I chose to perform my residency in an army hospital (although I can perform my residency anywhere- no obligation to the amry here) What they get- 1- One year of service for every year i'm on their dime The deal is too good to pass up it seems. I don't want to derail this thread, but if there are any doctors here that would like to PM me a few pointers on how to ask for letters of recommendation for med school, I would really appreciate it.

Correct me if I'm wrong here, but I believe the stipend pay is in fact taxable. Your statement that military residency pay is double that of civilian is suspect. I'd like to see your figures. Gaining a residency is like anything else in the military--You request--you get--based upon needs of the military. Many new docs do not get the residency they desired at the time they desired.

There is an entire army (so to speak) of docs who will argue til the cows come home that the downside of the program far outweighs the up.

I'm not endorsing or condemning, simply urging indepth research. This program is great for some and horrible for others.

[SteveL]

Quote:

Originally Posted by FIRE'd@51 R-I-T I think you pointed out in another thread that what this really means is that the PCP doesn't accept Medicare assignment. So long as the PCP is accepting new patients (and some aren't - Medicare or otherwise) but not Medicare assignment, can't I go to the PCP, pay him his normal fee, and submit the bill to Medicare myself, thereby recouping whatever Medicare would pay for that service, and pay the rest out-of-pocket (much the same way as going to an out-of-network provider with regular insurance). I don't see how a PCP could legally refuse to see some Medicare patients (i.e. the new ones) and treat other established ones, unless he were taking no new patients, period. Either he accepts Medicare assignment for all patients, or he doesn't. I think I am paraphrasing what you pointed out in another thread. Please correct me if I am wrong.

If you are a medicare participant, the PCP cannot bill you for more than Medicare will reimburse. They would be forced to reimburse you for the difference.

The PCP problem here is that many are not accepting any new patients because there is a shortage of PCP's.

[JOHNNIE36]

SteveL:
I'm looking at a Medicare Summary Notice (explanation of benefits). I have my doctor office visit billed to Medicare @ $115, Medicare approved $88.27 and Medicare paid $70.62. I am billed for the remainder of $17.65. This doesn't agree with your post. Am I missing something? Please explain.

[Rich_by_the_Bay]

Quote:

Originally Posted by SteveL If you are a medicare participant, the PCP cannot bill you for more than Medicare will reimburse. They would be forced to reimburse you for the difference. The PCP problem here is that many are not accepting any new patients because there is a shortage of PCP's.

Close but maybe not quite:

A participating physician cannot bill you for more than medicare will allow, not what they will reimburse. They can bill you for copays, deductibles and uncovered services as applicable. Example: usual fee is $140; they allow $100, reimburse at 80% of that. MD can bill patient for $20 and has to write off $140 - $100, or $40. Another: patient gets a house call, physician bills for transportation/travel time at $50. Medicare does not cover physician travel time, so it denies it as "uncovered," MD may bill patient for the $50 (plus the fee for the house call as in the prior example). To add to the fun, the physician must document that the patient was told in advance that it was likely that MC would not cover the travel costs (for every such uncovered service, at every visit).

While there is a shortage of PCPs and it will get worse , that is by no means the whole problem. Even if there were PCPs on every corner, if they are reimbursed at an amount that barely covers their costs they will not remain in practice, or will cherry pick the best payors to play with. One could argue about what the annual net income of a physician "should" be but given the training time and costs and the hours, stress, and legal exposure inherent in the profession it needs to be appropriately high, if not obscene.

Just some insight into why it is a high maintenance deal for both patient and physician.

[JOHNNIE36]

Rich in Tampa:
Lost all my health care coverages 1-1-09, This included health care, drugs, dental and vision. Signed on with a Medicare Advantage Plan. It has $3350 max out-of-pocket per year (not including drugs, dental or vision). Would appreciate your opinion on Advantage Plans vs the standard Medicare with a Supplemental Plan. I guess there are so many why's and wherefores that it's hard to give a solid answer but would just enjoy your thoughts. I know there are probably good and bad of both out there. At least you can change every year if you want.

[Rich_by_the_Bay]

Quote:

Originally Posted by JOHNNIE36 Rich in Tampa: Lost all my health care coverages 1-1-09, This included health care, drugs, dental and vision. Signed on with a Medicare Advantage Plan. It has $3350 max out-of-pocket per year (not including drugs, dental or vision). Would appreciate your opinion on Advantage Plans vs the standard Medicare with a Supplemental Plan. I guess there are so many why's and wherefores that it's hard to give a solid answer but would just enjoy your thoughts. I know there are probably good and bad of both out there. At least you can change every year if you want.

Johnnie, unfortunately I really don't know anything about the wrap-around packages such as you mention. Some have restricted panels of physicians to choose from.

Let us know what you learn.

[Martha]

Here is a good Medicare guide to various options: http://www.delawareinsurance.gov/dep...ideCurrent.pdf

[SteveL]

Medicare Advantage plans are possibilities for some right now. However, they cost Medicare significantly more, in the many billions, and there is a move in
Congress to eliminate these extra costs. The plans started as a Republican program. Who knows what will happen to folks who went that way if it stopped.