PCP 'subscription' charge

[disneysteve]

Consistent primary care is good for patients. Unfortunately, with the current model of an ever changing group of doctors employed in clinics the future doesn't look bright. A hospitalist may make an adverse change in medication to something that has already failed. If the patient doesn't pick it up the randomly assigned outpatient doc might miss it in his/her 10 minute slot

Exactly. The true value of a good PCP is continuity of care. One person who knows your entire medical situation and is coordinating all aspects of treatment. There can also be the soft benefit of the provider knowing your extended family. In my practice, I had many 3-generation and even some 4-generation families that I cared for. I don't need to ask as much about family history when I already know the whole family.


One thing I've definitely seen with big corporate practices is the turnover that occurs. When a doctor owns his own practice and builds it from nothing over many years, he tends to stay put and be there for decades. Not so with the employee doctor who might only be in a practice for a few years and then move on when a better opportunity presents itself. The continuity is lost every time that happens.

 

[ShadowBloom]

One thing I've definitely seen with big corporate practices is the turnover that occurs.

My doctor, who I've seen for 20 years, was part of an independent multispecialty practice of about 50 doctors, including at least a dozen PCPs. Then a few years ago, they sold to a group of 600 doctors, and then that group merged to form an even bigger practice.

In the past few years, most of the original, experienced PCPs have left the practice, and the remaining ones no longer accept new patients. There's a steady stream of new doctors coming and going, and I mean new. One of them is so inexperienced he lists a residency merit award (not a chief residency) in his biography. My doctor is still there, but he's gotta be 65 now. I'm dreading the day he retires and I have to find someone new.

 

[RetMD21]

The local hospital is charging a "facility fee" in addition to the usual charge for the visit. Although patients complain there are fewer independent doctors to go to.

I could be wrong but whereas disneysteve might have taken pride in doing a few office dermatology procedures for his patients' benefit the new breed may not be seeing how that helps them personally

 

[disneysteve]

I could be wrong but whereas disneysteve might have taken pride in doing a few office dermatology procedures for his patients' benefit the new breed may not be seeing how that helps them personally

Totally. The majority of doctors today are employees, not practice owners. Their employer typically dictates what they can and can't do in their office so even if they wanted to do minor procedures they probably aren't allowed to. In the big picture, it's not cost effective for each PCP office to be stocked with the necessary supplies for things they might only do occasionally. It makes more sense to send those patients to specialists who do those things day in and day out.

 

[Koolau]

As I said, "for the most part, I managed my patients' medical issues except for the really complex ones"

Sure, if you have a-fib you should have a cardiologist. If you have any type of cancer, you should have a specialist for that. But even then, the PCP can/should be pretty involved. When my a-fib patients were on Coumadin (blood thinner), my office did their ongoing blood work and managed their drug levels. We didn't send them out to the cardiology Coumadin clinic.

I was referring more to routine "specialty" care. The vast majority of patients with high blood pressure or diabetes don't need a cardiologist or endocrinologist. If you have an under active thyroid, that's something a PCP can manage. A PCP can easily remove a skin tag without making the patient wait a month or two for a dermatology appointment for a 5-minute procedure.

Agreed that my situation is probably not typical - especially for a 40 or 50 year old. Heh, heh, but I'm pushing 77! And I AM very appreciative of the inputs from my PCP. He does keep track of all my specialists' care. He is typically more responsive to my requests for info and explanation than my specialists.

Finding a good PCP is golden.

 

[Koolau]

Usually the hospital wants to get that inpatient daily physician charge. I'm aware of a local practice that was still seeing their own inpatients until they sold out to one of the hospitals last year.

A primary care from out of town told me that he wasn't allowed to see his own patients in the hospital. I didn't ask for details but I wondered if it was just a matter of the hospital giving the billing to the hospitalists.

Consistent primary care is good for patients. Unfortunately, with the current model of an ever changing group of doctors employed in clinics the future doesn't look bright. A hospitalist may make an adverse change in medication to something that has already failed. If the patient doesn't pick it up the randomly assigned outpatient doc might miss it in his/her 10 minute slot

Yeah, I think most of the care changes in the past 10 years (like hospitalists) are simply ways to defeat the gummint restraints on how much doctors can make.

My previous PCP got mad at me on an office visit (a follow up) when I asked him a question about something else I was concerned about. He said I should make a separate appointment to ask such a question.

He then launched into a (very controlled, quiet) 15 minute tirade on why he couldn't spend an extra 5 minutes with me. He couldn't make enough money when he had to spend the full allotted time with his patients.

Within a year, he became a hospitalist. It obviously paid more to stop into patients rooms, look at their charts for 2 minutes, maybe listen to their hearts, ask how they're feeling, maybe tweak something and move onto the next bed. That's GOTTA be a lot more patients per hour/day than a PCP gets to see.

I really do think a lot of what we're seeing is driven by money. I like to think most doctors do their best for patients, but they also are looking out for their own welfare. It's to be expected that they will adapt to changing compensation paradigms. YMMV

 

[OldShooter]

... I really do think a lot of what we're seeing is driven by money. ...

A few years ago we went on a Galapagos trip on a 16 pax boat. Another couple was English doctors, he a hospital executive and she a pulmonologist. We had lots of interesting discussions over evening drinks. The manager had spent a year at NIH early in his career and his comments were about his amazement that in the US system everything was about money.

 

[Katsmeow]

I'm not a fan of the concierge model as it leaves a lot of patients out in the cold. The ones who are willing and able to pay the fee whether it be $200 or $500 or more get good care, but the rest are left having to find a new PCP in an environment where doing so is harder than ever. ...

Primary care is dying and nobody really seems to care or want to do anything about it.

I actually have thought about both of these. When we moved to a new state 6 months ago we knew no one. I knew it was challenging to find new doctors knowing nothing and new that it was hard to get that first appointment. So DH and I decided to go with an MDVIP practice which is $1800 a year for each of us. This is honestly expensive for us and not an easy cost to choose to pay. But, we can do it although I would rather spend that money on other things. For many people it is not an option at all. It does bother me.

I also think the existing primary care model has problems. Someone mentioned preferring to use specialists for most things. I sort of agree. For years I saw my primary care doctor maybe once a year or less. For a lot of what they did an urgent care would have been fine. A year or so ago, it was a weekend and I absolutely knew I had a urinary tract infection. It made no sense to wait to see the PCP so I just went to an urgent care.

Primary care doctors were mostly useful to get referrals to specialists. Not so much the referral as I am on Medicare and don't need one. But, to get a recommendation.

At that time of my life paying $1800 for MDVIP would have been totally wasteful.

I've had MDVIP since August and, yes, you can tell the difference. The big thing is the time. I had an initial visit with my new PCP and it lasted over an hour. I had an issue that we weren't sure what was going on and he ran several tests, referred me for an ultrasound, called me to discuss the results. They initially referred me to a specialist practice. I couldn't get an appointment for 6 months! When I called back to the PCP's secretary she called around and found me an appointment elsewhere in 3 months.

They do all vaccines (except Covid) there in the practice. They are set up to do my Prolia injections (before I had to go to a specialist). They have an annual physical. They do run some non-standard tests (some heart stuff from Cleveland Clinic). They also do stuff that usually isn't done but can potentially identify problems. There is a 2 hour visit to go over the results. Since Medicare doesn't do physicals at all this is a true benefit that I could not get without paying out of pocket for it. It was far more detailed than any other physical I had done when I was on regular insurance.

Now the physical is certainly worth some actual money since Medicare doesn't cover them. But that isn't why I pay the $1800.

Having moved to a new locale the immediate benefit was being able to see someone right then rather than waiting months for an initial appointment and being able to quickly get specialist recommendations. But, that reduces in importance now that we are here and have specialists we have found.

So not sure if we will continue the $1800 for each of us. The big benefit of the concierge practice is the time the doctor spends with you. Also, just the knowing that if you have something you want to ask about or need to see him you can get a response quickly. It was made clear it was OK to contact on nights and weekends. And since I am paying $1800 for the privilege I am more willing to call if needed.

The reality is that the insurance system is such that primary care doctors have to schedule way too many patients to be able to have hour or 2 hours long visits with patients. Most visits of course won't be that long with my current doctor but the point is that they can be.

I have sympathy to the primary care physicians. They are asked to do a lot but don't get the reimbursements that say my interventional cardiologist gets. My current doctor put out a video on why he switched to the concierge model and basically it was to be able to be a physician and to spend the time he needs to do that. It is bad, of course, that this isn't available to all doctors and all patients and that it comes down to money. But, I have to deal with reality as it is.

For this reason I am not sure the primary practice model works well. Urgent care for the stuff like my urinary tract infection works well. And, for someone who only sees specialists they don't need the primary care doctor. t years ago I didn't need one. But, as I've gotten older I have started to have more of those chronic problems and I need someone who does know everything and can see the big picture and help direct me. When I see my cardiologist he doesn't really want to talk much about other parts of the body and so on. What I really want is I guess someone who is compensated like a specialist but tries to coordinate everything. And, for now, that means paying for concierge in my situation.

I honestly don’t know what PCP is for. I have a cardiologist, dermatologist and urologist I like and will always prefer going directly to a specialist than talking to a PCP. No wonder they’re a dying breed.

 

[disneysteve]

I have sympathy to the primary care physicians. They are asked to do a lot but don't get the reimbursements that say my interventional cardiologist gets.

Another problem, which I don't think we've mentioned, is that PCPs get paid a whole lot less for doing the exact same thing as a specialist. That needs to change. I mentioned removing a skin tag, a very simple dermatology procedure. 10 minutes tops. I don't have exact numbers but let's say a dermatologist would get paid $200 for doing it. A PCP might get $50, if it was even reimbursed at all, even though both had done the very same thing.

 

[RetMD21]

....He then launched into a (very controlled, quiet) 15 minute tirade on why he couldn't spend an extra 5 minutes with me. He couldn't make enough money when he had to spend the full allotted time with his patients.

Within a year, he became a hospitalist. It obviously paid more to stop into patients rooms, look at their charts for 2 minutes, maybe listen to their hearts, ask how they're feeling, maybe tweak something and move onto the next bed. That's GOTTA be a lot more patients per hour/day than a PCP gets to see. ...

Also less paperwork and administrative burden as a hospitalist If, like many, he is employed by the hospital there is an alignment of interests. The independent doc might make a case for why his patient needs more time in the hospital. The employed physician is less likely to do so. He (or she) has to watch is metrics.

Another problem, which I don't think we've mentioned, is that PCPs get paid a whole lot less for doing the exact same thing as a specialist. That needs to change. I mentioned removing a skin tag, a very simple dermatology procedure. 10 minutes tops. I don't have exact numbers but let's say a dermatologist would get paid $200 for doing it. A PCP might get $50, if it was even reimbursed at all, even though both had done the very same thing.

That doesn't seem right. I don't understand these "medical home" programs they seem like an awfully complicated and labor intensive to try to get a little more money to primary care. Fair reimbursement seems more straightforward.

 

[sengsational]

Also less paperwork and administrative burden as a hospitalist If, like many, he is employed by the hospital there is an alignment of interests. The independent doc might make a case for why his patient needs more time in the hospital. The employed physician is less likely to do so. He (or she) has to watch is metrics.

They get paid for what they can code, so a-coding we will go. The obvious result is what can't be coded won't get done. Need help appealing an arbitrary rejection of a prescription that should be covered? There's no code for that...you're on your own. Ah, but the insurance company will only talk to the doctor that wrote the prescription! Then the doctor's corporate boss comes down on the doctor for "wasting time". The lesson to the doctor: "I won't do that again" and so writes a different prescription or none at all, despite that being obviously sub-optimal. When those above in this thread observe is all about money, that couldn't be more correct. About the only thing patients can do is slam them in the survey. Not that it does much good, but it's the only stick the patient has. The sad part is that the people in the system are "good", but the system forces them into actions that are not the right thing for the patient.

 

[Koolau]

They get paid for what they can code, so a-coding we will go. The obvious result is what can't be coded won't get done. Need help appealing an arbitrary rejection of a prescription that should be covered? There's no code for that...you're on your own. Ah, but the insurance company will only talk to the doctor that wrote the prescription! Then the doctor's corporate boss comes down on the doctor for "wasting time". The lesson to the doctor: "I won't do that again" and so writes a different prescription or none at all, despite that being obviously sub-optimal. When those above in this thread observe is all about money, that couldn't be more correct. About the only thing patients can do is slam them in the survey. Not that it does much good, but it's the only stick the patient has. The sad part is that the people in the system are "good", but the system forces them into actions that are not the right thing for the patient.

Keep in mind that gummint pays for an awful lot of health care - and especially the health care of folks 65 and over. Because they pay, they want to control the prices of everything - including the doctor's fees. Paying your own fees (like subscription fees) means the docs can make enough along with what the gummint pays.

I don't really like the system, but it won't go back to the way it was before MC (and other gummint programs.) It may go farther toward the gummint paying. I'm not sure that's a good idea, but it sounds too political to discuss.

I feel that I have been blessed that MOST of the things I need to get done can be done fairly quickly. My doc seems to be able to get me in in a day or two for a quick look for an illness. Most of the specialists get me in within a couple of weeks. There have been exceptions - like my spine doc. Oh, and he COULD have done my "shots" in his office (he did once) but found out they weren't covered by MC unless I did them in an operating theater at the hospital (5 people plus one prep person for 30 minutes instead of 10 minutes in his office by himself - not even a nurse.)

SO I contend that it's the intimate connection between gummint and health care that is the biggest driver for the subscriptions. Like it. Don't like it. Use it. Don't use it. But be aware of why it might be a good idea for you. Be aware of why it might become necessary for a lot more of us. I can say no more because YMMV.

 

[MichaelB]

Keep in mind that gummint pays for an awful lot of health care - and especially the health care of folks 65 and over. Because they pay, they want to control the prices of everything - including the doctor's fees. Paying your own fees (like subscription fees) means the docs can make enough along with what the gummint pays.

I don't really like the system, but it won't go back to the way it was before MC (and other gummint programs.) It may go farther toward the gummint paying. I'm not sure that's a good idea, but it sounds too political to discuss.

I feel that I have been blessed that MOST of the things I need to get done can be done fairly quickly. My doc seems to be able to get me in in a day or two for a quick look for an illness. Most of the specialists get me in within a couple of weeks. There have been exceptions - like my spine doc. Oh, and he COULD have done my "shots" in his office (he did once) but found out they weren't covered by MC unless I did them in an operating theater at the hospital (5 people plus one prep person for 30 minutes instead of 10 minutes in his office by himself - not even a nurse.)

SO I contend that it's the intimate connection between gummint and health care that is the biggest driver for the subscriptions. Like it. Don't like it. Use it. Don't use it. But be aware of why it might be a good idea for you. Be aware of why it might become necessary for a lot more of us. I can say no more because YMMV.

So, your theory is physicians are underpaid because government sets the rates, they are too low, and therefore physicians have concierge fees to compensate?

 

[athena53]

So, your theory is physicians are underpaid because government sets the rates, they are too low, and therefore physicians have concierge fees to compensate?

You addressed this question to another poster but that's how I see it. Have you ever looked at what your docs actually get for visits and procedures, compared to the "sticker price"? Whether those reimbursements are negotiated with Medicare or the insurance companies, most of them are pitiful. Take a look at the cost of malpractice insurance while you're at it. My sister had an OB-Gyn practice in SC and Mom told me that before a new doc could touch a patient she had to fork over $50K for Med Mal coverage. And that was claims-made, so it covered only claims filed against the new doctor in that first year. Rates multiplied from there as the doc had more years of experience and thus more exposure to claims filed from prior years at each renewal. This was awhile ago; Mom died in 2016. BCBS had a lock on that state- if you wanted to deliver babies you'd better accept what BCBS paid.

Sister eventually became a hospitallist. She's retired now.

 

[braumeister]

For primary care physicians in the USA:

• Medscape Physician Compensation Report 2023: Average income is $265,000.
• Bureau of Labor Statistics 2022: Median annual wage is $211,420.
• ZipRecruiter: Reports an average annual salary of $217,445, with a range of $190,000 to $244,500.

Those are averages for the country, with California physicians at the top, making much more (about double the average) and Mississippi at the bottom, a little below the average.

 

[MichaelB]

You addressed this question to another poster but that's how I see it. Have you ever looked at what your docs actually get for visits and procedures, compared to the "sticker price"? Whether those reimbursements are negotiated with Medicare or the insurance companies, most of them are pitiful. Take a look at the cost of malpractice insurance while you're at it. My sister had an OB-Gyn practice in SC and Mom told me that before a new doc could touch a patient she had to fork over $50K for Med Mal coverage. And that was claims-made, so it covered only claims filed against the new doctor in that first year. Rates multiplied from there as the doc had more years of experience and thus more exposure to claims filed from prior years at each renewal. This was awhile ago; Mom died in 2016. BCBS had a lock on that state- if you wanted to deliver babies you'd better accept what BCBS paid.

Sister eventually became a hospitallist. She's retired now.

I have read the anecdotes and looked at the data. The Census Bureau collects and reports on earnings by profession. Of the top 20 highest earners, 19 are physicians. Primary care is 16th on the list. See here. US physicians out earn their peers around the world.

Contrary to what was stated by a previous poster, “the government” does not set fees for health care providers. For some, “the government” is a tired trope responsible for all of social ailments. Medicare (CMS) has a board called MedCAC (see here), comprised mainly of physicians and other health care providers, and they recommend fees for specific services, each of the thousands of billing codes. CMS can accept or reject, but usually accepts, and then applies. This is only Medicare, however. Private insurers negotiate their own fees with physicians.

I have posted elsewhere that I think PCPs are not well reimbursed, and this is a loss for society. About 15% of primary care physicians have opened some type of concierge practice. I hope it works out for them. I think the real issue is too much money goes to specialists and not enough to PCP. This is an issue in part created by physicians.

 

[sengsational]

For primary care physicians in the USA:

• Medscape Physician Compensation Report 2023: Average income is $265,000.
• Bureau of Labor Statistics 2022: Median annual wage is $211,420.
• ZipRecruiter: Reports an average annual salary of $217,445, with a range of $190,000 to $244,500.

Those are averages for the country, with California physicians at the top, making much more (about double the average) and Mississippi at the bottom, a little below the average.

^Interesting. Do the corporate overlords typically pay the malpractice insurance, I wonder?

 

[athena53]

^Interesting. Do the corporate overlords typically pay the malpractice insurance, I wonder?

When my sister joined as a hospitallist they paid hers. The catch, though, was that it covered only claims made while she was employed there. She had to buy "tail coverage" for any future claims filed due to work she did before she joined the hospital. She would also have had to buy another policy on retiring for the hospital for future claims arising for her work there; not sure who would have paid for that.

 

[RetiredHappy]

My PCP at Kaiser (N. Cal) made more than $350K a year and my OBGYN made more than $500K a year. But Kaiser is the best paymaster as I have been told.

 

[Koolau]

So, your theory is physicians are underpaid because government sets the rates, they are too low, and therefore physicians have concierge fees to compensate?

At least that's part of it. I don't think the gummint specifically sets the doc's wages, but the reimbursement rates pretty much set the parameters. At least that's what my previous PCP told me.

I get a bill that says "so and so doc" just charged you $337 for an office visit. MC approved $69. (Bogus numbers, but sorta like that.) The doc has to get his share (after the nurse does my BP/weight/meds review and after the 4 nice ladies in the front office get their share, and the rent is paid on the nice office, and HECO get's their $0.40/KWh, etc. And Queens Medical gets first dibs before anyone else.) Not much left over for the doc who (in early 50s is still paying off loans) had to spend 10 to 20 minutes with me (or dictating/typing my visit to the computer, etc.) YMMV

 

[Aerides]

At least that's part of it. I don't think the gummint specifically sets the doc's wages, but the reimbursement rates pretty much set the parameters. At least that's what my previous PCP told me.

That rate is set by the Insurance co.

 

[Koolau]

That rate is set by the Insurance co.

MC IS my main insurer.

 

[Chuckanut]

Another problem, which I don't think we've mentioned, is that PCPs get paid a whole lot less for doing the exact same thing as a specialist. That needs to change. I mentioned removing a skin tag, a very simple dermatology procedure. 10 minutes tops. I don't have exact numbers but let's say a dermatologist would get paid $200 for doing it. A PCP might get $50, if it was even reimbursed at all, even though both had done the very same thing.

My PCP used to do these small things. He once told me he enjoyed doing small procedures like removing troublesome moles, skin tags and ingrown nails. Now, they are all referred to a dermatologist. So, it’s two appointments when one would do. His new masters at the Medical Mega Corp that bought the practice dictate these things.

Thankfully, I have a very skillful dermatologist and I simply make the appointment with him for any skin related issues. He actually has a waiting list to cover cancellations. It’s rare I am on the waiting list for more than two weeks. With regular Medicare, I can go straight to a specialist if I need to do so. No need to wait for the PCP or the insurance bureaucracy to approve it.

 

[MichaelB]

At least that's part of it. I don't think the gummint specifically sets the doc's wages, but the reimbursement rates pretty much set the parameters. At least that's what my previous PCP told me.

That Medicare reimbursement rate was recommended by a group of physicians and other health care providers. They are the ones saying 15 minutes of a PCP is worth $69 while the specialist, such as my ophthalmologist, gets $369 for the 10 minutes (and sometimes even less).

I get a bill that says "so and so doc" just charged you $337 for an office visit. MC approved $69. (Bogus numbers, but sorta like that.) The doc has to get his share (after the nurse does my BP/weight/meds review and after the 4 nice ladies in the front office get their share, and the rent is paid on the nice office, and HECO get's their $0.40/KWh, etc. And Queens Medical gets first dibs before anyone else.) Not much left over for the doc who (in early 50s is still paying off loans) had to spend 10 to 20 minutes with me (or dictating/typing my visit to the computer, etc.) YMMV

Well, your PCP does bill other services during the day, and if he’s like mine, has a large office with many employees that do billable tasks.

So, how can it be that the PCP earns so little yet the cost of medicine is so high? One factor that contributes is physician specialists earn so much, while PCPs earn much less. The difference is so large it motivates PCPs to not deal with any health issue that can be seen by a specialist and instead maximize the number of patients they can see in a day, because that’s their business model. That’s why they try for concierge models.

The same situation affects doctors and health care for people <65. It’s not a problem created or caused by government. It’s more like the outcome of insurers and physicians all trying to maximize their income at the expense of each other, and PCPs are left with the short straw.

 

[Koolau]

That Medicare reimbursement rate was recommended by a group of physicians and other health care providers. They are the ones saying 15 minutes of a PCP is worth $69 while the specialist, such as my ophthalmologist, gets $369 for the 10 minutes (and sometimes even less).


Well, your PCP does bill other services during the day, and if he’s like mine, has a large office with many employees that do billable tasks.

So, how can it be that the PCP earns so little yet the cost of medicine is so high? One factor that contributes is physician specialists earn so much, while PCPs earn much less. The difference is so large it motivates PCPs to not deal with any health issue that can be seen by a specialist and instead maximize the number of patients they can see in a day, because that’s their business model. That’s why they try for concierge models.

The same situation affects doctors and health care for people <65. It’s not a problem created or caused by government. It’s more like the outcome of insurers and physicians all trying to maximize their income at the expense of each other, and PCPs are left with the short straw.

I can't disagree with any of what you have said. It's a mess, but we still have amazing (if expensive and inefficient) health care in this country.

I personally would not trade our broken system for any of the "great" EU/Commonwealth models of "free" health care for all. Sorry. That just slipped out.