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Should doctors be scared of government mystery shoppers?

| Kevin's Take | June 27, 2011

The government is going to find out about the primary care physician shortage for themselves.

They’re resorting to “mystery shoppers,” used frequently in other industries, to see what the wait times really are for a new primary care doctor. As mentioned before, come 2014, there will be over 30 million newly insured patients looking for a doctor.  This will further stress a system short of primary care resources.

Doctors, as expected, aren’t happy about these disingenuous calls from the government.

Some choice quotes from the New York Times:

Plans for the survey have riled many doctors because the secret shoppers will not identify themselves as working for the government.

“I don’t like the idea of the government snooping,” said Dr. Raymond Scalettar, an internist in Washington. “It’s a pernicious practice — Big Brother tactics, which should be opposed.”

Dr. George J. Petruncio, a family doctor in Turnersville, N.J., said: “This is not a way to build trust in government. Why should I trust someone who does not correctly identify himself?”

Dr. Stephen C. Albrecht, a family doctor in Olympia, Wash., said: “If federal officials are worried about access to care, they could help us. They don’t have to spy on us.”

Dr. Robert L. Hogue, a family physician in Brownwood, Tex., asked: “Is this a good use of tax money? Probably not. Everybody with a brain knows we do not have enough doctors.”

Studies from professional medical associations already quantify the primary care shortage.  According to the Massachusetts Medical Society, for instance, over half of primary care physicians aren’t accepting new patients.  The average wait time for an appointment in internal medicine was 48 days.

Wes Fisher, the cardiologist-blogger at Dr. Wes, is firmly against the move, likening it to government-sponsored phishing:

When information gathering trumps patient care – particularly fictitious care — we’ve got a problem. Is this a new quality standard we can expect from our new government health care initiative?

Kent Bottles comes down on the other side:

I disagree with my colleagues that a properly planned and implemented mystery shopper program is a bad idea for trying to improve health care. For far too long, we in medicine have been too arrogant to learn lessons from other industries that improve quality. I think we need all the help we can get to take better care of patients.

It’s concerning that the government has to resort to guerrilla tactics to confirm what physician-organized studies already show: yes, there’s a primary care shortage.  But if they need to see for themselves how dire the situation is, perhaps they can act more emphatically to provide more primary care resources.

If that means fielding a few calls to provide fictitious appointments, that’s an acceptable price to pay.

Kevin Pho is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on Facebook, Twitter, and LinkedIn.

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  • doc99

    Government “Mystery Shopper” program is simply battlespace prep for mandatory participation in Health Insurance programs.. And why not? Did not the AMA endorse Mandatory Insurance coverage? In for a penny, in for a pound.

  • Smart Doc

    The Law of Unintended Consequences:

    More than a few doctors are on the verge of dropping all Medicaid involvement, and a smaller number are on the fence with Medicare.

    Could yet another poorly thought out and dogmatic Obama anti-doctor campaign actually decrease patient access?

    Lets not forget that there is a 30% drop in Medicare fess scheduled for January 1, 2012, and $600 billion in additional Medicare cuts mandated in the “Patient Protection and Affordable Care Act.”

    Will this “mystery shopper” campaign be the tipping point to force even more doctors to drop out of Medicaid and an escalating number to out of Medicare?

    • Family Medicine Doctor

      “Could yet another poorly thought out and dogmatic Obama anti-doctor campaign actually decrease patient access”

      Could you describe how this will decrease patient access? Im not sure it does, but im willing to hear your concerns but with specifics.

      It sounds like the gov just wants to verify what and where the shortage is. Since they are the payer, why is that so wrong? If i was paying, you better believe I would want some verification. Are we asking for the gov to trust us with no verification of our statements? We would not appreciate it if the roles were reversed and we were told to trust someone without verification. In business, this is simply not done.

      “Lets not forget that there is a 30% drop in Medicare fess scheduled for January 1, 2012, and $600 billion in additional Medicare cuts mandated in the “Patient Protection and Affordable Care Act.” ”

      This article is about the mystery callers, not reinbursement and not Obamacare. Could you insert how your comment was related to Dr Pho’s post?

      BTW, i get it. You’re angry at how we treated as primary care physicians (are you a PCP?). Im angry too. Very. But “Will this “mystery shopper” campaign be the tipping point to force even more doctors to drop out of Medicaid and an escalating number to out of Medicare?” I think not. Of all the nonsense i must deal with, a few phone calls by the gov to determine access of care of the community to my office is not an issue. Low reinbursement is. If a doc is going to drop out of Medicare ( very very unlikely, lets be honest), a mystery phone call is not going to push him/her over cuz its not the main issue, not even close.

      I gotta agree with you on Medicaid. It pays worse than lousy. Full disclosure: I do not have a medicaid contract. No way.

      • Smart Doc

        I am asking: Will “mystery shopper” hassles will have precisely the opposite effect from the benefit that the bureaucrats claim for this program?

        Wouldn’t it be cheaper just to ask some real world doctors how to inexpensively improve access to Medicaid and Medicare, rather than this disrespectful Mickey Mouse espionage?

        Will doctors considering having nothing to do with government health insurance be pushed over the edge and opt out of Medicaid and Medicare? The impression given is that this is the first salvo of a larger Administration plan to demonize the doctors.

        Will the future of Medicare be Alaska and Manhattan, two locations where no PCPs are taking new Medicare? How much value is a mystery shopper where the access drops to zero?

        • Fam Med Doc

          “I am asking: Will “mystery shopper” hassles will have precisely the opposite effect from the benefit that the bureaucrats claim for this program?”

          No, they won’t. A few phone calls is not THAT onerous onto a practice. If it is, then I would say the doctor was already leaving.

          What is onerous is the low reimbursement we get as primary care doctors, not a few phone calls. It’s the low pay of Medicaid that pushes doctors “over the edge and opt out of Medicaid”. Everything else can be annoying on varying degrees of nuisance but will not push us out.

          “Wouldn’t it be cheaper just to ask some real world doctors how to inexpensively improve access to Medicaid and Medicare, rather than this disrespectful Mickey Mouse espionage?”
          Real life shoppers is NOT espionage. That’s an exaggeration. Real life shoppers are an appropriate & occasionally utilized tool by businesses to evaluate a specific question. In this situation it’s access. And yes, asking docs how to improve the system should be a part of an evaluation, but directly observed, quantifiable data- like in our science lab classes in undergrad, remember- can add a significant amount of important & useful info.

          I think this mystery shopper program has the potential of providing an important result to our understanding of how health care is delivered in the US. For instance, I live in a very large urban setting. There are primary care docs in every corner. I think there is no shortage in my area. I would like the data to support, or refute, my hypothesis.

          • Smart Doc

            The problem is that you are not dealing with an honest consumer agency.

            You are dealing with the current Administration, as corrupt, totalitarian, and agenda driven as they come.

  • Peter Wei

    Alternate headline: “federal agency to probe the mysteries of supply and demand”

    On a serious note, this is actually valuable information for policymakers to have. But once it hits the political world, the results are all too likely to be spun as “greedy docs” rather than “flawed policy assumptions.”

    • Joe

      Thanks for the smile Peter. I am still waiting for anyone in government or their cheerleaders to admit to any flaw in policy.

    • Primary Care Internist

      you are right about the “greedy docs” mentality. Most smart free-thinking people would be surprised to hear how many other smart people in all facets of business feel that all docs have a moral imperative to see all comers regardless of ability to pay, including medicaid.

      When my friends in the financial industry imply that, i ask them if their “2% of assets” fee for financial management is mandated by the gov’t to decrease to 0.2% for those with less ability (or motivation or willingness) to pay, they STILL feel that docs must just take it and shut up.

      • stitch

        Read the comments on the NYT attached to the article. I was shocked to read many of them yesterday; they absolutely reflect that opinion of “greedy docs” out there. And how many seem to forget that yes, it’s a business, we have to pay the bills too.
        Do not people realize that docs are only human, that we, and our STAFFs, cannot handle every single patient that needs or demands care? And I must say that as rough as it is for docs when faced with this attitude, it’s the front desk people who bear the brunt of it.

        • http://msrenegade.com Marie

          Stitch, that is a really fair point and, you are right, one that has been completely overlooked.

          Not everyone who calls an office is polite or reasonable or even rational. That is a stressor on staff and on the doctor. And you all are only human.

          Unfortunately, in my five year odyssey of chronic illness and then a terrible injury, I have encountered mostly impatience and rudeness from front line staff. Maybe it is because some of them are burned out, but it is incredibly distressing when you call for an appointment, as pleasant as can be, and you are treated like an annoyance. Or worse.

          It just goes to show there is so much work to be done.

          And I must go on record saying I do not think the vast majority of physicians are greedy at all. I respect their need to make a living and, again, believe we have a far way to go to institute an equitable reimbursement system.

  • Doc ForthePeople

    I do not like the idea at all, especially if it goes beyond the steps leading up to scheduling an appointment. The heart and soul of the doctor-patient relationship is TRUST. There are too many bad outcomes and mistreatments and misdiagnoses if the doctor does not trust the patient and trust what the patient is saying. If these mystery patients start dysrupting that relationship of trust any more than it has already been disrupted by insurance companies, and regulators, working together, then the sanctity of the doctor-patient relationship will be utterly destroyed. Medical ETHICS is not just about care of the dying patient but now intersects with the face to face meeting between a doctor and a (?fictitious)patient!

  • http://roseblum@aol.com GingerB

    The literature I read is mixed on what access is like. You read here that many many are turning down Medicare/Medicaid patients and access is in a crisis state. Then you read on national news that most don’t have problems finding a doctor. Which one is right?

    A survey that’s designed properly should cut through all this antidotal evidence and tell us with predictable certainty what it’s really like to be on the calling end of the phone trying to get an appointment with gov’t sponsored insurance.

    If some regions or areas have problems it’ll be a welcome roadmap for improvement. If the situation isn’t as bad as the stories we read in various media outlets then there will be facts to back up why those groups/regions don’t need more resources.

    • Fam Med Doc

      Dear GingerB,

      I agree. What is so threatening about the government collecting data? The government is the payor source. They want to know about access of care in the US. It’s perfectly logical to me.

  • Mike

    Plenty of other industries are subject to secret shopper programs. In some industries, government inspectors can even drop by anytime they want to conduct a surprise review.

  • Joe

    I’m sure one or another policy wonk, when debating whether government-funded insurance should pay for a given potentially diagnostic study, brings up the important question of whether or not the result of said test will alter a potential treatment plan. The same question must be asked of this survey. How would the result change the way Medicare and Medicaid deal with providers? If there is no plan of action to deal with the result of the survey, one must wonder whether the survey itself is nothing more than a political tool.

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    Just a quick reminder that this mystery shopper concept was introduced last year at the Healthcare Reform Summit by Senator (Dr.) Tom Coburn (R) as “undercover patients”. So much for blaming everything on Obamacare….

  • Matt

    Physicians, with the encouragement of the AMA, got in bed with the government 40 years ago. Now they do not appear inclined to get out of bed and hop back into the free market. So you’re in a partnership with the most powerful partner in the world.

    I have to ask – how did you THINK this was going to go? Did you think that everytime that you said “we need X or Y will happen (usually fewer docs somewhere or higher costs)” the government was going to give in indefinitely?

    Until you opt out of the third party payment system, this is your lives. In fact, it only gets more like this.

  • http://nourishourselves.blogspot.com Marie

    It will truly be a shame if this initiative causes even more hard feelings between physicians and the government. Doctors are so put upon already and we need to work together for an improved health care system. However, I think as a study this could produce some very interesting and helpful data.

    I commented on today’s Times article and my comment was highlighted by the editors, #505 (http://tinyurl.com/3kyba4g). From my perspective, this is a huge customer service issue. The driver is the person who answers the phone and the majority of the time that is not the doctor. There are many wonderful doctors out there who are not necessarily wonderful managers. As a result, staffing can be their weakest link.

    As I said in my Times comment, I have experienced staff to often be rude, abrupt and controlling, acting as though your request to see the doctor is the most preposterous thing they have ever heard. I have good private insurance but frequently staff I speak to act irritated about giving me an appointment or annoyed that they have to do some work.

    Give it a chance! This project could identify significant areas of opportunity. I guarantee poor customer service will be one of them. Physicians in their practices need to be very aware of how their front desk interacts with patients and they should insist their staff be respectful and polite to everyone, no matter what kind of insurance they do or don’t have. Patients call because they have problems, the last thing they need is someone giving them even more of a hard time.

    • http://www.dialdoctors.com Dial Doctors

      Customer service is right and appropriate. We’re in the business of providing health care through telemedicine and we’re subject to mystery shoppers.

      I personally have called the doctors and pretended to be a patient just to learn how they are working. I did so for our blog too while I was using every area of our service.

      It’s not viewed as an imposition or espionage; it’s simply verifying everything is working as it should be.

      These calls are not intrusive and only require a couple of minutes from the office staff. Besides does it matter if the person that’s calling is from the government? Will the answer be any different?

      I can understand why doctors may initially consider the measure as intrusion but it doesn’t appear to act that way. There were no discussions about penalizing doctors for any particular situation or anything like that.

      Is there a shortage of doctors? Yes but just how much is what we don’t know yet.

      Give it a chance is the best reaction to this survey.

  • solo fp

    A positive aspect of the mystery shopper could be some insight into the wait times for patients. Many practices have a 3-4 week wait for new Medicare patients and a 6-8 week wait for new Medicaid appointments. In my area, only 2 practices are willing to see Medicaid patients.
    As a negative aspect, the next step could be mystery patients inquiring about narcotics and disability. They may even send in actors to test the doctor’s true documentation.

  • Rebecca Mitchell

    Is everyone commenting here aware that the average doctor actually LOSES money on clinic overhead (paying staff, making a salary that is already at most 1/2 of what any other non-generalist practitioners makes, the building, equipment, etc) to take a Medicaid patient? And that is the national average, California for example is even worse with its horridly funded MediCal program. And this burden is placed on primary care physicians who are already hundreds of thousands of dollars in debt and are paid 50% or less than procedural based specialties that do not train for any longer period of time or work any longer hours. (ie, anesthesia, radiology, dermatology).

    These numbers are already all out there through dozens of independent studies that demonstrate the lack of access for both the uninsured, underinsured, and those with private health insurance alike, dozens more explore the causes of this varied access. There are NO new questions being answered that any idiot who understands PubMed could not do a meta-analysis on.

    Primary care doctors are suspicious because this answers no new questions, and only reeks of the government trying to argue that we treat Medicaid and Medicare patients differentially. Its easier to call the doctor the greedy bad guy than admit that they underfunding these public programs to the point that they are nonfunctional. Its actually a rather genius political move on their part.

    If you want quality primary care doctors and enough competition in the system (ie, enough primary care docs so that every practice isn’t so overloaded that you are at their whims) so that YOU as a consumer can use your own market power to avoid clinics with poor customer service, long wait times, etc; large numbers of quality medical students need to be attracted en masse again to primary care. That is not going to happen until they are compensated in a way so that family medicine, general internal medicine, and pediatrics are no longer the bleeding heard joke of specialties. As consumers you all need to understand that your insurance dollars are being used to prop up this ridiculous system where nobody is truly incentivized beyond the goodness of their heart and love of their patients to give you the best care possible in the setting in which you will receive 95% of your healthcare over a lifetime.

    • e-patient

      1. I don’t have the option to pick my own insurance. My employer picks the plan. While I might chose an employere based on their healthcare options, in this economy, I don’t have that option. I could buy my own individual policy but since I don’t have several pre-existing conditions, it’s unlikey I would be offered a policy.

      2. All the primary care clinics I have been to have poor customer service. The wait time to see a physician is long. Urgent problems are taken care of by nurse practitioners. Appointment times are short, the quality of care is substandard. Perhaps if I had an affordable alternative, I would use my market power to make a point. The “cash price” is significantly higher than what insurance pays.

      3. Those of us who care about our health and have the ability to do so have moved away from primary care. My market solution…the only one I have available…is to manage my own care. My PCP doesn’t have the time. This is not an insult, just the reality of the situation.

      4. I receive my medical care in a market based system. If a doctor doesn’t like my insurance reimbursement, s/he doesn’t have to sign a contract. Perhaps then, I could make another market based decision and decide whether I am willing to pay more for better service.

      5. Anything that would solve the problem with access and reimbursement is offensive to some…

      • Mike

        I also manage my own care, and it has gone much better for me. I started doing this after too many instances where my records were never sent over, a call was never made, etc. It isn’t a criticism, just a fact of how busy a doctor’s office is. Frankly, it isn’t much work to manage my own care. More people should do it.

      • http://warmsocks.wordpress.com/ WarmSocks

        I’m sorry you’ve had such a bad experience with doctors.

        My family physician can usually see me within 2-3 days, or the same-day if it’s urgent. Appointments are scheduled for 20 minutes, but he takes longer if needed. Sometimes less time is required and we sit and chat before he heads off to see his next patient. He is sometimes late, but never seems rushed. I dread the day he retires and I have to find another doctor.

        Another doctor I see is also easy to get an appointment with. I have no idea how long he allows in his schedule but appointment are very relaxed. He has a couple old dogs that wander in and out of the exam rooms; some patients make a point of taking dog biscuits in for them. He does the exam, decides if the treatment plan needs any adjustments, we chat… He is NEVER running late – I always arrive early and sometimes (after a leisurely appointment) I’m out of the office even before it’s time for my appointment.

        If you’re getting substandard care, it’s time to search for a doctor who will take the time to listen and address your concerns (even if that takes multiple appointments). Good luck – there really are good doctors out there.

  • buzzkillersmith

    Mystery shopper=teapot tempest. But I did like the line in the NYT article about the government not being a reliable business partner. Right on.

  • Primary Care Internist

    “…only reeks of the government trying to argue that we treat Medicaid and Medicare patients differentially…”

    I think we, as doctors, should proudly and clearly answer to mystery shoppers that we do NOT take medicaid, and that medicare wait times are purposely longer than better-paying privately-insured patients. There is nothing morally wrong, illegal, or unethical about that. We are defending our own self-worth and the years of education and training and lost opportunity that we sacrificed to help others, that few others can appreciate. The gov’t is only trying to make us look like we’re hiding this phenomenon, and when it appears this way, it gives creedence to the false notion that we are required by law to see everyone (and promptly) regardless of insurance coverage. Many many people think it is wrong, or even illegal, for docs to take one insurance and not another, or to see aetna patients in 3 days, but medicare patients in 2 weeks. If we are just blatantly open about this phenomenon, people will get the idea that this isn’t discrimination, but just business.

    • http://msrenegade.com Marie

      Ack!! I literally choked on my tea when I read your comment.

      Of course medicine is a business, but a distinctly unique one. It is not a dry cleaner where if you have to wait two weeks for your clean suit no one is going to die. Doctors should not have to suffer undue financial hardship, but we are talking about human beings here.

      If you think the kind of discrimination you are describing is not a moral or ethical problem, you need a refresher course. Do you have any recall of the concept of beneficence – a practitioner should act in the best interest of the patient?

      There are moral and ethical ways of making a decent living as a physician without the draconian policy you have in place. Which, I might add, is almost certain to come back to bite you some day in some way.

      • Justin

        Incorrect, Marie. No one is going to die if they are delayed getting into their first PCP appointment. If it’s an emergency, go to the emergency room.

        • stitch

          And that is one of the criticisms of the questions being posed by the fake patients: a patient who has no relationship to the doc calls complaining of significant symptoms including fever and shortness of breath. The physician is under no obligation to accept this patient without a pre-existing relationship, has no idea of the patient’s previous history, and the patient calls with acute serious problems. The appropriate plan is to refer the patient to the ED or to some urgent care facility.
          Furthermore, it is not the doc who will answer the call. The office staff will answer the call. I wonder how many of these calls will ever even get referred to the doc him/herself.

        • http://msrenegade.com Marie

          Justin, on the surface I might agree with you.

          But I think of my husband, who hadn’t been to the doctor in years and had a history of pleurisy, complaining the pleurisy was bothering him. So call the doctor I told him and he said he would after the holiday (Christmas). If he had, he would have told them his pleurisy was acting up and he would have gotten a week to two week appointment.

          However what he really had, but didn’t know it, was angina. And he never made it to after the holiday because he died if a massive heart attack December 20, 1993. He was 40.

          That is how people die waiting for first PCP appointments. They don’t realize how sick they are or they minimize it. Some people, like my husband, would just never think to go to the ER. So it might sound implausible, but it’s not.

      • buzzkillersmith

        Discriminating against poorly paying pts has been standard practice in many private primary care offices for at least 22 years, since I started practice. Several years back my wife and I took over a practice in which we took all comers, with plenty of Medicare and Medicaid. Our practice went belly-up in 22 months. This is frequently the reward of the “ethical” doctor.
        Although I sympathize with your outrage, it is simply an axiom of life that the way to get people to do what you want is to pay them well to do it. Moral persuasion has, in my experience, been much less effective.

        • http://msrenegade.com Marie

          Twenty two months? If that isn’t depressing, nothing is. Do the right thing and get screwed.

          I’m so sorry.

          I don’t know what to say except it is yet another example that something’s got to give.

          • Primary Care Internist

            again, read my post. there is NO obligation to accept a new patient with an insurance that is under-paying. this is not a matter of ethics at all, just business, just like a grocery store has no obligation to give away food at lower prices to poor people.

      • http://www.youtube.com/watch?v=ji_G0MqAqq8 AustrianSchool

        PC Internist is correct and Marie is wrong. PCPs have to have a balance on their patient census with cash pay, private insurance, state-funded payers, etc. If you take all comers ASAP, your practice will be overwhelmed with state-funded payers and this is not a sustainable business model. So, accepting new Medicare/caid patients is done but only a set number a day or a week to maintain balance. It is the ethical thing for a physician to do to maintain professional balance as well as balance in his personal life because state-funded patients are usually the most taxing from a mental and emotional standpoint, not just financial. This leads to delays in new appointments but it’s not unethical at all. Calling it unethical is saying you believe physicians are slaves, which is unethical. The patient calling for a new appointment is not my patient yet, they are someone else’s until I see them. All I can do is try to provide excellent care for my patients. I cannot take every new patient that calls. I am not a serf and I am not greedy. Because I set limits, I am a better doctor for the patients I have. Because I set limits, my current patients are able to get same day appointments and better care.

    • Fam Med Doc

      I am VERY PROUD to state I do not accept Medicaid in my office. It pays worse than lousy. And I most certainly do not feel any moral obligation to anyone who doesn’t pay me enough to cover my overhead & provide me a decent salary.

      If more docs did this, Medicaid would die or it would increase it’s reimbursement rate. Then I would accept Medicaid in my office. I have no problem seeing poor people. For real.

      Really colleagues, why do you accept Medicaid? Does it really help you or more likely hurt you financially? Obviously I’m only talking to docs in private practice who have a say in the contracts the office makes.

      • Primary Care Internist

        It is very sad to me, and insulting, to see that even seemingly bright people who post on this board indicate clearly that they feel it IS our obligation to treat everyone, to the point of taking on the liability of a new medicaid patient we have never seen with cough / hemoptysis / chest pain / whatever, for the gov’t's lousy $30 (medicaid payment in NY).

        Meanwhile the same gov’t pays a hospital-based clinic 4-5 times that rate for a resident or NP to see that same patient, and gives the hospital subsidies for taking on medicaid & “self-pay” patients – subsidies that don’t get passed onto those doing the work & taking on the liability, but rather go towards administrators’ $500k – $1m salaries. The same gov’t pays podiatrists $300 to resell sneakers to diabetics, or $500 to ambulette companies to transport nursing home residents with medicaid to subspecialty clinics.

        As FMD says above, if everyone declines medicaid something will have to change. I’m not holding my breath for everyone dumping medicare, but for medicaid i just don’t get why ANYONE in private practice accepts it. To me that is just denying our own self-worth.

        • http://msrenegade.com Marie

          To you, Primary Care Internist, accepting Medicaid patients is denying your self worth.

          To others, it is doing the right thing.

          I guess it just boils down to the kind of life one chooses to lead and whether you can sleep at night.

          • stitch

            Marie, did you get what PCI is saying?

            Do you know about facility fees? Medicaid can pay up to 4 to 5 times for the same visit if the client goes to a hospital based clinic or to an FQHC that it does if that patient comes to a private physician’s office. Is that right? Is that “doing the right thing” on the part of Medicaid? And why should physicians have to accept that?

            It’s kind of hard to sleep at night if you are worried about paying your bills or having to lay off staff, too.

          • Fam Med Doc

            Dear Marie,

            Did YOU NOT READ buzzkillersmith response on how he went BANKRUPT when he accepted Medicaid? Is that what you want for me, too? I sleep better at night cuz I DONT take Medicaid. Yet, you might think it’s all swell for me financially cuz I don’t accept Medicaid, but even by not accepting Medicaid it’s hard for me to pay my bills. Very hard. In July, just a few days away, I’m sweating cuz I gotta pay payroll taxes to the Feds. I hope I have it. What part of low reimbursement for primary care docs don’t you understand?

            Doing the right thing does not mean putting myself, my office, and my patients at risk financially. Where will my staff go for jobs in this recession when I close? Where will my patients go for care?

          • buzzkillersmith

            To fam med doc,
            We did not go bankrupt, but we did lose money and predicted continuing and worsening losses. Bankruptcy would have been a possible outcome if we had stayed, but we closed the practice before any severe financial distress occurred. Just before we left town I saw a pt of mine at the video store and he asked why we were leaving. I said “Too much work and not enough money.” He seemed stunned. Most people have no concept of the sorry state of primary care economics. But they’re learning.

  • Rebecca Coelius

    I think an even bigger moral problem is if we as a society think healthcare should be a basic human right for Americans, but aren’t willing to raise our taxes or be politically active to shift the systems money around to properly fund a program to do so. If this is a societal imperative, it should be born equally by all of us, not stuck on the shoulders of an individual actor. I pay my taxes too, why do I have to pay again and again with long hours, a horrible work schedule, worse pay than any other specialty in medicine, and sub par care to ALL of my patients because I have to rush through every one (which I would also argue is immoral)? Why should I be in debt for several hundreds of thousands of dollars that stays with many doctors decades afterwards? Do you understand that this system actually has medical students weighing the importance of being able to help pay for their children’s college education versus going into primary care, in all but the most rural areas where the cost of living allows you to pay back your loans more quickly? The fundamental reason we have a shortage in primary care is that our health care system has systematically undervalued them.

    Stop blaming doctors, start ensuring the system incentivizes people to do what you want them to.

    • buzzkillersmith

      Good post. To me, the single most demoralizing aspect of being a family doctor is constantly having to worry about being able to pay for college for my kids. I did not expect that when I went into family practice.

      • stitch

        And there’s a whole other story in that, how the cost of education has escalated beyond almost all other things (except the overall cost of healthcare) while incomes have remained stagnant – INCLUDING for primary care physicians.

  • Smart Doc

    UPDATE: The Obama Administration Dumps this “Study”:

    Rather than answer Republican questions about their so-called “Secret Shopper” program, the White House abruptly dropped it.

    And what were the questions being asked?:

    “We have deep concerns regarding the department’s recent plans for a ‘stealth survey,’ its legality, notification to Congress and lack of standards for any misconduct or bad reporting by the staff hired to carry out this work on American doctors and their practice of medicine,” asked Senator Mark Kirk (R, Illinois) . “The cost and proposed clandestine method of collecting information from physician offices are questionable and, therefore, we request details of how this survey would be conducted, how investigators would be punished for misconduct or extortion and how patient/physician confidentiality would be maintained.”

    • Fam Med Doc

      I agree smartdoc, those are reasonable questions to ask (more or less) if that makes paranoid docs more comfortable with the survey.

      And I still hope the survey occurs- there might be some good information & then an even better response from society in regard to primary care. I’m just not afraid of a few phone calls from mystery callers. I’m just not.

      But smartdoc, you wrote as an answer to a question of mine earlier “You are dealing with the current Administration, as corrupt, totalitarian, and agenda driven as they come.”. You still haven’t answered questions of mine on access of care or Medicare rates. Full disclosure: I’m neither Democrat nor Republican, but intentionally non-partisan. Yet, you your political views shine thru, loud & bright. Is it possible, and please be professionally honest here, that nothing this administration does is right in your eyes? Maybe for you this isn’t about mystery shoppers, but Obama?

  • imdoc

    The title of this article should give everyone concern. Do we want a country in which the citizens are paranoid and feel victimized by the “government”? In a functioning democracy, the elected officials should be constantly wary of losing their position by not serving the interests of those who vote.

  • Max

    I have to say, when I hear Obama describe medical conditions and mis-pronounce medical terms and discuss diagnostic and therapeutic options, I cannot believe any physicians supported this effort. He’s discussing medicine as if he has first-hand knowledge and he calls a nebulizer a ‘breathalyzer’? Some of you guys supported this “genius’” ACA? Really?

  • http://msrenegade.com Marie

    Stitch, Farm Med Doc, I stand by what I said.

    I agree that Medicaid reimbursement is scandalous. However, there are ways to balance it in a practice, many doctors do.

    I also said something’s got to give. There has to be a better way. The only way to find that better way is through bipartisan consensus. And as we can see from the comments not just here but on nearly every post, that is nigh on impossible. Everyone is so intent on grinding their own axes, throwing stones, being right, having the last word.

    Finding a better way will take trial and error. And compromise. And sacrifices. But very few are willing to take chances and even fewer are willing to sacrifice. It is very hard not to feel despair for the future.

    • http://deleted pcp

      Wow.

      “fewer are willing to sacrifice”

      Speak for yourself.

      Primary care docs who practice outside of large hospital clinics sacrifice everytime they see a Medicare or Medicaid patient. But you enthusiastically condemn them for not enjoying the privilege of paying (yes, paying, not being paid) for the work they do.

      How much cash do you take out of your wallet and give to your boss each day you go to work?

      • Smart Doc

        There are quite a few people in this country (many more in Europe) who want only the best things in life for free.

        It is not just medical care, but everything. At some point, you run out of other people’s money to spend. At that point, you get bloody riots in Athens, Greece and Madison, Wisconsin.

        • stitch

          um, there were no bloody riots in Madison. Not a valid comparison.

          • Smart Doc

            There were plenty of death threats in Madison, after the cash flow ran out of the budget. Entitlements breed violence when the money comes to an end.

          • stitch

            I need some evidence of that. A big part of the issue in the protests in Madison was about people who happen to be employed by the state getting paid for doing their jobs.

            In some ways, it’s more akin to docs actually trying to get reasonable reimbursement from the state/federal government for doing their job, a big part of the discussion here.

        • gzuckier

          “There are quite a few people in this country (many more in Europe) who want only the best things in life for free.”

          Yeah; like being able to see a doctor regarding the wear and tear built up from 40 years of working for a living, without that meaning you need to eat dog food for the next month. Greedy!

    • stitch

      You know, it all goes back to the issue that there is a shortage of primary care physicians in this country. And you wonder why. It’s partly an issue of pay, but it’s also an issue of, frankly, unreasonable demands on the parts of multiple players.

      Personally, I am employed, and salaried. My pay doesn’t matter whether I see Medicaid patients or not. And I do see them, but it is aggravating to know that when I worked in a hospital based clinic Medicaid would pay 4 times what my current employer gets when billing for my professional fee.

      I have all the sympathy in the world for docs in private practice who have made the decisions they have made regarding payors and even those who have gone to retainer medicine. I have chosen this path, but it comes with significant costs as well.

      Bottom line? The bottom line is the bottom line. If we want people to have access to high quality primary care, then we need to value that high quality primary care. And that means paying for it and letting primary care doctors do the job they were trained to do.

      Unfortunately everything is going in the wrong direction on that.

      Don’t ask me to sacrifice any more. The next sacrifice I make will be to leave the job behind.

    • Fam Med Doc

      Dear marie,

      “I agree that Medicaid reimbursement is scandalous. However, there are ways to balance it in a practice, many doctors do.”

      You continue to miss the point. Doctors are NOT balancing the financial matters on Medicaid patients. They are not paying themselves a salary (yes, there are primary care docs ive met them who are doing so bad cause of low pay, like from reimbursement from MEDICAID, that can’t pay themselves), closing their clinics (buzzkillersmith for example), telling their children or medical students to not go into primary care, or even leaving primary care completely. Is a doctor “balancing it” when s/he can’t save for his/her retirement or their kids college education due low reimbursement from Medicaid? MEDICAID is killing primary care.

      You really don’t see this? You admit it’s “scandalous” but we should continue to be involved with it? Just accept not getting paid sometimes? And when Medicaid does pay, it’s so low it didn’t pay the overhead to cover resources (rent, staff salary, etc) that Medicaid pt consumed.

      • http://msrenegade.com Marie

        I have to admit it is making me smile that you are being so polite and writing “Dear Marie” before proceeding to lambaste me. I suspect you are a very nice person. As I believe the rest of the docs here are. :)

        I don’t think I am missing the point, but maybe I am. I won’t argue with you. But I also did say there HAS to be a better way. You are all so smart. I am not being facetious, I mean it. You guys are so, so smart. All of you working together, with the government, could come up with some sort of solution to this reimbursement morass.

        But no one does work together. Not in the government, not in the industry.

        It can happen on a micro level. I think of how an OR team works together with one focus: the patient. Everyone knows their role and works in concert with everyone else. Personal BS is checked at the door. And I think of the constant initiatives undertaken to improve this already well-oiled machine, the checklists, time-outs, etc. A surgeon is not concerned if his scrub nurse supports Obama or if the anesthesiologist is a Republican. It’s all about getting the job done well and right. If we could take this model, which works so well, and apply it at the macro level this issue would be done.

        But it won’t happen because no one can seem to check their personal BS at the door. Everyone has their own agenda and is convinced they are the only one who is right. This president is crucified because he mispronounces some medical terms, another president from a different party would be just as vilified by the other side. And the game goes on and everyone is bitter and the docs lose and potential docs lose and the patients lose. Everyone loses.

        • Primary Care Internist

          wow talk about lambasting:

          “To others, it is doing the right thing…” “…I guess it just boils down to the kind of life one chooses to lead and whether you can sleep at night…”

          I sleep fine at night (except when on call). Just curious, what is it you do for a living? presumably you are in some field of some value to someone, that they therefore pay you for. Why don’t you, tomorrow let’s say, give back your daily net income to your employer. Do this one day every two weeks so you can “sleep at night” and “do the right thing”. That way he can go spouting off how he is doing such a great job providing a service, and you can hopefully still pay your bills. And if you can’t make ends meet after that, just take solace in knowing that you have fulfilled your ethical responsibility to those benefiting from your employer’s productivity at your expense.

          That’s exactly what happens when a practice accepts 10% medicaid. But you seem to not understand that, no matter how simply it’s put. Your agenda of equal access for all is blinding you to practice realities. And as another poster states, forcing someone to work (even us greedy doctors) is still a violation of their freedoms and SLAVERY!

          • http://msrenegade.com Marie

            Gosh, so cranky! As I said, I won’t argue anymore and I will concede that perhaps I don’t know what I’m talking about.

            As far as what I do for a living, I am a nurse and I worked in Managed Care for many years, eventually at the senior executive level. I was also the Director of Admissions for several years at a local hospital. I was diagnosed with MS in 2005 and gradually became too sick to maintain the standard I expected of myself in management, so for two years Care Coordinator, working in PCP’s offices to monitor their sickest patients.

            I am no longer able to work. I do volunteer work (helping people with finding jobs) and I write. I believe people put a value on what I do now, but it is not a monetary one. And no, lol, I cannot pay my bills nor do I sleep very well at night. I am a widow and have no other income. I am losing my house, I am losing everything I ever worked for because of MS. Or, as I call it, MS, the gift that keeps on taking. Even though I can’t make ends meet, I do take solace in the fact that I provided well for my four children (one now a lawyer :) ) after my husband died and I have lived the best life I knew how. Which, I know, is what everyone here is trying to do as well.

          • http://msrenegade.com Marie

            Sorry, typo in my second paragraph, the last sentence should read “…so for two year I WAS a Care Coordinator…”

        • Primary Care Internist

          and the kind of life i choose to lead??? the same as anyone else – to work hard, contribute something valuable to society, and provide for my family, and even have some happiness in the process. What is so wrong with that?

          • http://msrenegade.com Marie

            Doctor, there is absolutely nothing wrong with that. Nothing. Your family is lucky to have you.

        • Fam Med Doc

          Dear Marie,

          I see NO immediate solution to our current healthcare crisis (1-5 years). And none in the intermediate (10 yr) future. Maybe in the long term (25 years)- and that’s if we start to work on the issues now, but we won’t. So the cost of healthcare in the US & the taxes we pay to fund it will only increase. And the coverage that each individual plan gives will diminish & the individual will have increasingly larger out of pocket expenses.

          Why am I so gloomy? End of life care & obesity in our country lead to the top 2 causes of illness, disease, & death (in the form of Cardiovascular disease & Diabetes). And the cost to treat them will only increase. 30% of the US population is currently obese, not overweight, OBESE. This will not change. Do you really think that the obesity epidemic is curable?

          Nor will the high cost of end of life care diminish. Rather, its gonna increase. The baby boomers are retiring & this HUGE population demographic will cause an ENORMOUS demand of healthcare cost in the last few months of their life (it already happens now, it’s just gonna worsen). There is NO way to stop this useless, futile end of life care runaway train that we are on.

          Don’t believe me? Remember Palin screaming “death panels”? Remember a HUGE part of the population believing her?

          Back to the Dr Pho’s original post way above: No one will let the government try to address the situation. All they wanted to do is make some phone calls & use that data to address some issues. And see, the government can’t even be allowed to do that. And we want them to provide a solution to obesity epidemic? Oh, stop. And fix the futile & costly expenditures of end of life care? Puleeze.

          No, our healthcare system will stay broken for a long time.

          • http://msrenegade.com Marie

            Wow, when you put it that way, it almost makes me grateful for having an incurable neurological disease that is rapidly eating away at my life. lol

            I get what you are saying and I don’t disagree with some of your predictions. But I maintain that we must hold our legislator’s feet to the fire and demand change, refuse to allow the status quo to continue. It is possible and the onus is on us to accept nothing less.

  • Rebecca Coelius

    One issue that hasn’t been brought up in the whole “just balance your practice” discussion is how little leeway doctors have charging publicly funded patients for services that Medicaid does not reimburse for at all, or at a loss. The number of regulations around this would make your head spin. Doctors who do try to get around them by using methods such as charging a measly yearly $100 or so as a clinic “membership fee” and the like are demonized as boutique or concierge practices. Its utterly ridiculous and the general public has no idea to what extent a physicians hands are tied to even make small changes in their own practice to be financially sustainable.

  • Leah Thronson MD

    There is a more ominous aspect to “mystery or undercover patients’”. In the “war on drugs” which is felt by many of us, in reality, to be a war on patients and Physicians, Some undercover patients are working with the DEA and law enforcement agencies to look for doctors who they believe are indiscriminate in their prescribing habits. Sadly these folks from law enforcement know little about medical care, and often astoundingly little (for the DEA) about medications (ex, lamotrigine is not a controlled medication, severe treatment resistant depression may require augmentation with a controlled medication, 70% or more of patients with depression have a co-occurring and often disabling anxiety disorder, chronic pain is real and a challenge to diagnose and treat, the latest list of controlled medication is not 2002, college students sometimes do have ongoing ADD/ADHD and are not always abusing adderall and so on. Bankruptcy is surely a terrible experience. Spending 10 years in prison may be worse. How many “plants” have appeared in your practices? I know of eight in mine and no doubt there have been others. Am I good enough to spot them? Not always. Do I like being suspicious of patients? It is entirely antithetical to my training and instincts and I am sure to yours. Leah Thronson MD Psychiatry

  • Penny

    What? Americans doctors are subject to things like “mystery shoppers?” Wow, that’s really kind of shocking. It’s like having mystery shoppers for lawyers or politicians! I just can’t believe that!

  • Fam Med Doc

    Dear Tony,

    Yes, I agree 100%.

    I actually have a hypothesis: some of the ones most outraged are the ones who take Medicaid but limit the appointments. For example- an Aetna PPO & a Medicaid pt call at the same time for f/u appointments to see their pcp (they are existing patients of the practice). The Aetna pt gets an a appt in 2 days, the Medicaid pt in 11 days.

    I understand the issue. The doctor has GOT TO balance the number of visits per day to where are at least SOME of them are actually going to pay his overhead & his salary. Medicaid is a loss, so limiting those Medicaid appointments is one strategy.

    But I don’t think that’s ethically right. It somehow feels like those patients gotta sit at the back of the bus. My answer is to not have a Medicaid contract. But then again, those docs who do this practice could VER EASILY criticize ME & say at least they are trying to help the poor in some way compared to me who has shut the door on Medicaid.

    I commend all my colleagues who accept Medicaid. Your generosity & compassion is impressive & what makes primary care great. For real. But if you limit their access, it does seem questionable.

    We have a terrible healthcare system.

    • Fam Med Doc

      Dear Tony,

      Yes, I’m well aware of ACO’s. But not very many patients as a percentage of the US population will be in one for many yrs, except for a few with the first medical groups that sign up as an ACO. It maybe 10 yrs till a large chunk of the population is enrolled in one. Or more.

      And although I might hope ACO’s work out, they are still a hypothetical- we not 100% SURE they are gonna work. But I hope they do.

      But Obamacare really doesn’t affect the true causes of runaway healthcare spending: obesity & end of life care. So will ACO’s really decrease the cost of healthcare in the US? I am beyond skeptical.

    • http://www.youtube.com/watch?v=ji_G0MqAqq8 AustrianSchool

      Tony, it sounds like you think this ACO business is a good idea. Have you really thought about it?

      …”If you don’t keep your assigned patient group healthy, the excess cost of treatment comes out of your pocket.”…

      Guess what will happen to non-compliant patients. They will be dismissed from the ACO practice so the ACO published ratings and reimbursements remain high. That kind of thing is already happening across the country today because many payor sources are rating doctors on things like A1c, mammo’s, paps, ACE-I for DM pts, microalbumin checked on DM pts, etc… The patients who refuse their bone density test and EKG get dismissed from the practice because by keeping them on, it dings the doctor’s “quality” status and reimbursement. Duh. .

      It used to be, a physician could discuss the risks/benefits of taking a statin and the patient could make an informed decision. Now, and with what you are talking about with ACO quality outcomes measures, the physician will tell the patient “Take this statin or else I cannot be your doctor.” Thank you government!

      • Fam Med Doc

        Dear Austrianschool,

        Tony seems very excited about the ACO coming to his town. I hope it works for him, gosh for all of us. It has its interesting points. He just doesn’t realize that his pcp DUMPED (meaning fired) all the doctors non-compliant, obese, frequent flyers from his practice just before the hospital practice bought it. And it’s what many, not all, practices will do just before they set up their ACO. it’s called practicality. And survival.

        I know I will be hated by people on this blog, but I think an obesity tax should be enacted. BMI’s 30 or over pay a fine. I would love to work with obese patients with some skin in the game.

      • http://www.youtube.com/watch?v=ji_G0MqAqq8 AustrianSchool

        @FMDoc, I understand your reasoning for wanting a tax on obesity. I differ from many posters here in that I do not agree with a collectivist mentality re: healthcare or welfare or anything else the gov provides. Healthcare, rather than being an individual’s right, is an individual’s responsibility. Obese patients should be on the hook to pay for their own care (ie not having the government punish health-conscious individuals by transferring their wealth to unhealthy patients). The free market does not really exist in this country but it should and it should apply to healthcare as well.

        @Tony, it is a mistaken assumption to believe a physician cannot dismiss a patient without just cause. That is simply not true. A physician can terminate the doctor patient relationship anytime, for any reason or for no reason. So can a patient. Doctors usually give 30 days notice to avoid abandonment issues. Check with any med-mal attorney, state medical board, or liability insurance carrier. Saying doctors must take care of patients regardless of the doctors wishes in the matter is a mentality of servitude towards doctors’ role and is unconstitutional. Alot of people don’t realize this, and I am concerned that the ACO outcomes business will transfer the doctor/patient relationship into administrators hands, and the administrators will send out dismissal letters to patients that are costing them money. It is an expected consequence, and in any other industry it would not be called unethical by the collective.

    • pcp

      “If you keep your assigned patient group healthy, you get to keep the money you save”

      And the most effective way to do this is to get all the sick patients out of your practice/ACO.

      “Sort of like your auto mechanic.”

      Not at all like an auto mechanic. The more work the mechanic does, the more he charges.

      • e-patient

        “And the most effective way to do this is to get all the sick patients out of your practice/ACO”

        Doctors already cherry-pick their patients. A patient with complex health issues can’t possibly get optimal care in the 15 minute drive by visits offered in todays healthcare climate. It only makes sense to see the easy to diagnose/treat patient where there is a textbook answer. If the patient needs anything more it’s a loss of profit.

  • gzuckier

    It’s against the second amendment. Or maybe the Bible. One of them.

  • Rebecca Coelius

    Do ACOs “lock” patients in for three years + too? What if I don’t like the specialists at this specific hospital, or my own Doctor for own matter?

    I’m all for global payments for patients, I think fee for service has created an enormous number of problems in the health system.But I’m leery of yet another complex structure in the health system making patients even less like consumers.

    Not trying to be abrasive, I truly don’t know the answer to the question.

  • Fam Med Doc

    Dear Tony,
    You wrote:
    “Most end-of-life events happen in hospitals. Can you think of a better way to tackle that problem than with the combined ideas and resources of the group providers in a Hospital ACO Group? I can’t.”

    Your optimism is noted. And it’s much better to be that way as the ACO change takes place. And I hope it works. Really.

    But obesity is a terrible disease. And it’s a worse disease to cure. Unless the patient has some financial investment in his/her own cure, it’s resolution will be elusive for the majority of affected individuals. I honestly believe their should be an obesity tax on the members taking part in ACO’s, all Americans actually. See, why should the doc take the financial risk of his obese pts who WONT lose the weight & who inevitably become sick as a secondary consequence of their obesity? Remember obesity leads to hypertension, high cholesterol, diabetes, all of which can lead to strokes, heart attacks etc which is the leading cause of cost to the healthcare system. You get the picture. So sure, I’ll take financial risk- that’s what the ACO is all about, if you keep your population healthy you have more money left over for you as the doctor- but I don’t want to be paired w patients who don’t care, unless they have some financial stake too.

    And you actually think an ACO will be able to convince the family “Grandma is 93. She is in the terminal phase of her dementia. She is bedbound & in a fetal position & hasn’t spoken to anyone in 2 yrs. She weighs 85 lbs. Now she’s forgotten how to swallow due to her dementia. She’s in a vegetative state- existing & no longer living. Let’s NOT put the G-tube into her & let her die a natural death-no tubes, no suffering, ok?”. Uh, Tony, I’ve been doing this long enough to know that what the family demands, is what they are going to get. Futile care with high cost be dammed. The ACO doesn’t address this. This applies to cancer too.

    No, the high cost of healthcare will continue cuz we can’t agree as a nation as to logical solutions. We are blue states fighting red. Republican fighting Democrat. Liberal vs Conservative. Even usually logical docs can’t agree on a simple government study of primary care access via phone calls. No, the US healthcare crazy will continue. ACO/Obamacare or not.

  • http://www.baird-group.com Kristin Baird, RN, BSN, MHA

    I am disappointed that this project was cancelled. The only way to make improvements in healthcare is to take off the blinders and take an honest look at the current reality of today’s environment. Frankly, it may have helped to shed light on the number of providers turning away Medicare and Medicaid patients due to the reimbursement structure. Providers have been grappling with this issue for years. This could have been the impetus to increase the reimbursement rates.

    • Fam Med Doc

      Exactly

  • Fam Med Doc

    “In fact, he needs a pretty good reason to “fired” a patient without just cause. Is being sick just cause?”

    No, a doc can fire a pt for any reason or no reason. Legally. Usually it’s for non-payment of bills, repeated no-shows, verbal abusiveness to staff or doctor, or non-participation in healthcare.

    I’ve been reading about the ACO’s, not really talking much to my colleagues. I stand by my concerns. They don’t address the major causes of runaway healthcare costs:obesity & end of life care.

    “the Hospital ACO he sold his practice to never once looked at his patient base for personal health criteria.”

    Of course they didn’t. They wouldn’t need to. But if there medical goals to meet (for example the HgA1c for diabetics for salary goals such as bonuses) they told him that & he may have responded accordingly by firing some of his worst offenders. PLEASE PLEASE don’t write back & say that you know otherwise. You don’t know, nor do I, what happens behind closed doors. Maybe he did, maybe he didnt. But the point is, as people have commented above, cherry picking will be a part of ACO panel formation for many doctors. It’s called survival & reality. Do you actually think he would air his dirty laundry to a pt? Unprofessional if he does. I wouldn’t.

  • Fam Med Doc

    I may sound a little “pollyanna” but my money is on the ACA and the ACO model as they way we tackle end-of-life care in the future.

    Yes, you do sound like her, which is fine. My point is that there is NOT ENOUGH evidence to so strongly believe your assertions. Yet, many of us want the ACO to work, but for you to be certain is not stance i nor any scientifically logical can take. Its an UNTESTED proposition. I will wait for the data to evaluate & then decide its sucess or failure. And I have read plenty on the ACO proposition. I do not see end of life care nor obesity issues adequately addressed. We will have to agree to disagree. But I’m glad you are excited about it. For real.

    And I have had plenty of counsel- a doctor can fire a patient. It’s called the right of free association. We will have to agree to disagree again.

    In regard to your 3 options to the fiscal Medicare crisis- I suspect there are more than 3 options available to society, but my point is we are too divided, angry, & demanding of a society to address this as a group & find a reasonable solution. Obamacare BARELY got thru. And it’s a once-every-40-years legislative feat. And it doesn’t fully (no where close as I have above stated) come close to addressing the issues. And it was only a start. It needs ALOT of follow up work which I don’t think the US society as a whole can produce.

    We couldn’t even agree on some simple mystery phone callers.

    • Fam Med Doc

      “Our firm is always there to protect an abused and misunderstood patient.”
      Yes, I’m sure you are. But you continue to fail to misunderstand me.

      “So, I’d be careful how you treat the patients you hold in such disgust and disrespect just because they ate too much and have a little weight problem.”
      I would not dismiss a patient with just “a little weight problem”. Nor would I suspect my colleagues. Did you NOT read my response above how usually the dismissal involves “non-payment of bills, repeated no-shows, verbal abusiveness to staff or doctor, or non-participation in healthcare.”. Perfectly legitimate reasons. We are talking about the 350 lb pt with refractory hypertension & on 4 meds, uncontrolled diabetes, high cholesterol, & non compliant with medication & refusing to lose weight. Thats the type of pt is a walking time bomb & the type I would consider dismissing- maybe another doctor could get thru to the patient where i am failing. Tony, you seem too smug with all your answers. A vast majority of pts being dismissed by a doctor are not “abused and misunderstood”. Look at the examples I gave above.

  • Hospice & Palliative Care Doctor

    Dear Tony,

    I was aware of groups such as hospitals, IPA’s, and even insurance companies purchase doctors practices but I read the article & it was interesting. Thank you.

    But you over exaggerate the impact. Yes, there are practices being bought, but most practices will still be ACO-free. But sure, if things work out with the ACOs, in 10 years a majority of Americans might be enrolled in one.

    My humble opinion.

  • pcp

    ACOs as described in the ACA do not exist yet. The rules defining them haven’t even been finalized. The article you reference is about insurers buying practices to increase both market share and corporate profits. Their primary responsibility is to their shareholders, and they will not apply to become ACOs if it looks like it will reduce their profits. Many large medical corporations have already indicated that they will not.

    Do you really think most people want to get their health care from doctors who work for their insurers?

    • Hospice & Palliative Care Doctor

      Very strong point. Very.

  • hawk

    Tony,

    Interesting views, but I have a couple of comment, questions, since you seem so aware of ACO’s..

    1) didnt we try this as the HMO model in the 80′s. i was a little too young, but seem to remember that didnt work out so well as pt’s did not get the care they needed, or wanted, due to the drive to control costs. In some cases, care was refused for the bottom line. I understand that some care may not be ‘needed’, but what do we do about the unhappy people, who do not get the care they ‘want’ as opposed to ‘need’, and end up giving poor pt satisfaction scores as a result, which in turn will lower an already low reimbursement.

    2) how do you think the ACO’s will handle people in certain specialties, like mine, for example, emergency medicine. for me, the only fair way to be paid seems fee for service. I perform a task or evaluate a patient, and get paid for that. I have no ‘patient population’ to contract with, the er welcomes all comers. I often provide the most acute, lifesaving care, but do not feel the ‘bundled payments’ would reflect this. and what about patient I consult on emergently.. people I have to intubate on the floor or place a central line in, shouldnt this be a fee for a service, what percentage of a ‘bundled payment; does an acute lifesaving intervention deserve? Will I have the option of just not doing them, because I will not be paid for them?

    You may see this as a solution, but I see nothing but problems. Remember, most of us are smart people, we went into medicine because we care, but expect to be rewarded for our hard work and sacrifice which has placed us behind the financial curve of our peers. on top of that there are issues like malpractice, jackpot juries, stupid federal mandates, and soon, without reward, many of us will choose to leave and just do something else. I already here the guys who have been in 20 years talking about early retirement, who will see patient when they leave.

  • http://www.metrowestphysicians.com Physician Services Admin

    This article presents the clear disconnect between governmental ideas / control and the rationale understanding of our health care paradigm change. It’s very interesting to think with our Physician shortage looming, the government has plans to utilize the State’s Medicaid plans as a conduit for open coverage for their citizens. The problem is that the govenment payors (Medicaid and Medicare) simply do not reimburse at adequate levels of the care rendered. To compound this issue, most physicians do not accept the governmental plans and more movement has been migrating from opting out totally of these plans to garner more VIP / concierage medicine as well as a better payor mix. So why would the government think our current Physician supply could handle more enrolled lives in State funded plans? All their secret shoppers will reveal is what the health care market already knows. Let’s just have them call and indicate themselves as a Medicaid patient and wait for the decline and frustration to find a provider who accepts their plan.

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