Primary care is caught in a bind by third party payors that supresses their compensation below what it is worth. The current FFS system is apparently not an appropriate way for primary care to charge. They are a profession and should themselves, even if it must be done one doc at a time, devise charge systems that rewards them for their most important work that than discouraging it.

I personally would love to find a PCP in my area who worked on a “retainer” basis. The much derided “traffic director” role of primary care these days would be very valuable for me even though as a physician I know the system better than most, and it would be worth 100$ a month for me to have someone that I could call and ask questions without feeling like I am imposing on his time. It would be a relatively small addition to my usual fees and health insurance premium and may would come back to me in more efficient utilizaiton of specialists.

I have had two relative recently who got low-tech assessments from their PCP’s, and conservative management advice. Being enamored of technology like most Americans, they weren’t happy with that and went on to spend large sums of money for high tech workups with the end result of precisely the same management advice.

What that tells us is that some people don’t value primary care and would just as soon take the revolving specialist approach. PCP’s need to stop trying to sell themselves to everyman and just sell themselve to those who value what they do best.

I for one admire them.

–an admiring specialist

1- would you let a nurse and social worker manage your mother’s diabetes?

2- i have never heard of, or received a bonus from an insurance company.

3- usually I am capitated & the specialists are FFS;

4- there is NO SHORTAGE of specialists taking even the crappiest plans in my area (GHI, HIP, blue cross HMO);

5- I matched & did a year in one of the most competitive medical specialties, then left because i saw little medical benefit in it (oncology);

6- please read your post and tell me who is being divisive (especially the first line);

sure, I’d LOVE to come to your business meeting – shoot me an email (seriously).

Providing triage services or treating self-limited conditions is hardly the work of a central player. I realize it is not your fault to feel the way you do, that the government even encouraged you to choose primary care. But you DID make the choice, even if it may have been by default when you did not match in that high-powered specialty you covet.

Do you remember that patient I referred TO YOU for the blood work at your lab, yes the one I never received a letter back about with the results, whose blood sugar was discovered to be near crystallization levels, that you then gave a card to go see an endocrinologist? Well he hasn’t made an appointment yet and is going to land in the ER in the meantime. What about your patient with the URI who thanked me for saving him a trip to the ER as your office recommended when nobody was available in your office or by callback Friday afternoon? Or the office staff member of mine with impetigo that was handed a prescription for Valtrex? And how about that HMO patient who anesthesia tells me needs a cardiology consult prior to surgery that you gave me a hard time about? I wish I could directly refer him, and I know that it costs you brownie points when that HMO hands out bonuses, but the insurance company won’t have it any other way and you can’t put my patient to sleep.

While I have you on the line, let this serve as notice that I am resigning from that health plan that pays you fee-for-service and capitates my services. You see, the postage on those letters to you explaining my findings just went up, halving my reimbursement in the process. And while you may think that you can just refer the patient to another specialist, guess what, there is no other specialist accepting that plan. So much for being able to refer to anyone you choose.

One last point, I am not able to bill for nor do I consider your referrals “consults”. In fact I am assuming care for problems you cannot handle. For this reason, Medicare no longer allows me to bill a consultation code. Then again, when did I ever send you a letter telling you how to manage a problem as a true consult would dictate?

In closing, just remember that old Soundgarden lyric from their song “Outshined”: “The grass is always greener where the dogs are sh*tting!”. This is reality.

Thank you for your kind referrals. If I may be of service you or any of your patients, please don’t hesitate to call me. In the meantime, I suggest that we remember that we are all in this together and nothing is gained by being divisive. It you really want to see some backbiting and class warfare, come to my business meeting. We have a 10 fold range of reimbursement and income among our subspecialists that would make you and I look like bloodbrothers.

It amazes me that a specialist can insult a referring pcp to the patient- that is just stupid. It makes EVERYONE look bad, & always gets back to the PCP, who then will withhold future referrals & never think of that specialist in the same light.

Many internal med specialists e.g. cardio, GI, endo, somehow manage to forget EVERYTHING outside of their specialty despite being boarded in IM, particularly when it comes to managing multiple meds in the elderly. Yet we are the “idiots”.

I’m sorry, was this written by a FP or by the NP who is now legally authorized to do everything he can?