Status quo primary care: How did things get this bad?

“Nine of 10 doctors discourage others from joining the profession,” writes Daniela Drake on the Daily Beast.

And stats say that by the end of 2014, about 300 physicians will commit suicide.

What is going on?

A few years back, practicing medicine was named the second-most suicidal occupation. Yet, it hasn’t stopped. The level of sheer unhappiness among physicians is on the rise.

Being a doctor has become a humiliating undertaking. There are those who feel that America has declared war on physicians — and both physicians and patients are the losers.

For one, consider the fact that in certain cases ER docs cannot charge less than what a chargemaster decides, even if that patient is financially burdened. Meaning, if that patient isn’t wrapped up in the red tape, he’s not getting the help he needs. And, if he does carry the proper affiliation (Medicaid, etc.), the doctor will have to work just to receive compensation for the work performed.

Not surprisingly, doctors want out. Seriously, there is a website known as the Drop out Club – which hooks doctors up with jobs at hedge funds and venture capital firms — and it has a legitimate following.

It’s difficult for people outside the profession to understand how ugly the affair has become — ICD codes, and end-of-shift dictations, and — let’s stop for a second. Does anyone really meet with 25 to 40 people in one day? Imagine that, you’re a top notch blogger. You work in the comfort of your living room. Could you imagine 40 different people parking, entering your living room, sitting on your couch, just to have a quick conversation about their enterprise, that you will have to briefly write about later that day, or tomorrow, and that you will have to follow up with next week, just to make sure everything you wrote went where it’s supposed to.

Chances are you don’t follow up because, oh yeah, you have to see 40 people per day just to pay your rent and earn enough money to pay your bills and your student loans (pretend it’s expensive to become this hypothetical blogger) and take home the market salary for a blogger.

Now, to make matters worse, let’s pretend there is a company, called DreamZone. And that this company’s sole role is to be available to pay you to create stuff that helps these clients who come to your house everyday. At the end of each day, you have an additional task, which is to communicate to DreamZone, what you did that day and what you decided on that day to do in the future. From there, DreamZone determines your reimbursement for the work you’ve already done, and, as it sees fit, tells you when it won’t pay you to do something you believe will help your client.

What a scenario, right?

But that’s fee-for-service healthcare.

Author Malcolm Gladwell implied that to fix the health care crisis, the public needs to understand what it’s like to be a physician. Imagine, for things to get better for patients, they need to empathize with physicians — that’s a tall order given the nature of our decidedly un-empathetic times.

After all, the public sees ophthalmologists and radiologists making out like bandits and wonder why they should feel anything but scorn for such doctors — especially when Americans haven’t gotten a raise in decades. But being a primary care physician is not like being, say, a plastic surgeon — a profession that garners both respect and retirement savings. Given that primary care doctors do the work that no one else is willing to do, being a primary care physician is more like being a janitor.

Unfortunately, things are only getting worse for doctors who still accept health insurance. Just processing the insurance forms costs $58 for every patient encounter, according to Dr. Stephen Schimpff, an internist and former CEO of University of Maryland Medical Center who is writing a book about the crisis in primary care. To make ends meet, physicians have had to increase the number of patients they see. The end result is that the average face-to-face clinic visit lasts about 12 minutes.

In fact, difficulty dealing with insurers has caused many physicians to close their practices and become employees. But for patients, seeing an employed doctor doesn’t give them more time with the doctor — since employed physicians also have high patient loads.

“A panel size of 2,000 to 2,500 patients is too many,” says Dr. Schimpff. That’s the number of patients primary care doctors typically are forced to carry — and that means seeing 24 or more patients a day, and often these patients have 10 or more medical problems. As any seasoned physician knows, this is doable, but it’s certainly not optimal.

Most patients have experienced the rushed clinic visit — and that’s where the breakdown in good medical care starts. “Doctors who are in a rush, don’t have the time to listen,” says Dr. Schimpff. “Often, patients get referred to specialists when the problem can be solved in the office visit.”

And that’s why I became a direct care doctor right out of the gate. Under the weight of red tape — all the third parties making money without providing actual care — fee-for-service physicians have to constantly improve their “productivity” just to keep their lights on. And now they have to keep their patient satisfaction scores up or risk losing their jobs. Industry leaders are so fixated on patient satisfaction, despite the fact that high scores are correlated with worse outcomes and higher costs.

Seriously, trying to please whatever patient comes my way destroys the integrity of my work. It’s a fact that doctors acquiesce to patient demands — for narcotics, x-rays, doctor’s notes — despite what survey advocates claim. And now that Medicare payments will be tied to patient satisfaction: This problem will get worse. Doctors need to have the ability to say no. If not, when patients come in for an appointment, they’ll have a hostage, not a doctor.

There’s nothing worse than the terror that accompanies a malpractice suit. Nothing. But what about the paranoia that comes with a doctor, worried about his patient rating, who doles out painkillers. God forbid the patient legitimately has drug-dependency issue and overdoses. Where’s the blame? On the doctor, again.

And of course this is rare, but this is the world of fee-for-service family care that our leaders are envisioning. This catch-22 — the fear of keeping your lights on and the fear of what might happen if you do — is not going to lead to optimal outcomes.

“There’s a media narrative that blames physicians for things the doctor has no control over,” says Kevin Pho, MD, an internist with a popular blog where physicians often vent their frustrations. Indeed, in the popular press recently doctors have been held responsible for everything from the wheelchair-unfriendly furniture to lab fees for pap smears.

No wonder doctors are suicidal. No wonder young doctors are repelled by the idea status quo primary care.

So how did things get this bad?

I’m not sure if I’ll ever be able to answer that. But if enough patients say, “I Want Direct Care,” maybe we won’t have to.

Josh Umbehr is founder, Atlas.md.

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  • Patient Kit

    So, you’ve been direct care for your whole medical career, post-residency? (In your words, you became a direct care doctor right out of the gate.) With all due respect, if direct pay is such a great model and that is how you practice, why do you sound so miserable? Equating being a primary care doc with being a janitor? Also, if DPC is so great, why haven’t more docs and patients quickly embraced it? Is that the media’s fault too?

    If you’ve read any of my other comments here at KMD, you’ll know that I don’t in any way minimize the problems of our healthcare system for both patients and doctors. But I really do not believe that the public — aka patients — hates doctors the way you seem to believe we do. From where I sit, there is still plenty of love and respect out here for doctors among your patients.

    As for doctors who are dropping out of medicine for jobs with hedge funds and venture capital funds, I have to question the motivations of why those doctors went into medicine in the first place, if those are their top second career choices.

    Finally, here is my most recent experience as a patient in our system this month: Three weeks ago, I saw my GYN oncologist for one of my every 3 months post-surgery/OVCA dx checkups. He’s an attending based at a good NYC teaching hospital. Excellent doc, very popular doc, the best doc I’ve ever had. Technically great and with an amazing personality, compassionate, good communicator. Yet I never have a problem getting an appointment to see him. If it’s an emergency, I’ll get in right away. If it’s a routine checkup, when I call, I get an appointment within a week or two. I’ve seen him maybe 8 times in the year and 3 months that he’s been treating me, including surgery and one day overnight in the hospital. He often has residents with him but he has been the one treating me. Once I saw his PA when he was out of town at a conference. I can’t imagine a better experience with a doc than I’ve had with this employed doc. Oh yeah. I’m almost never left waiting in the waiting room long. I usually go in within 10 minutes of arriving.

    Yesterday, at the same teaching hospital, I was seen at the primary care medical clinic. I called at 3:30 the day before and got squeezed in the next day at 4:30, 24 hours later. In that clinic, I’m treated mostly by a resident under attending supervision but it almost always the same resident. Yesterday, I really only went in for an Rx. But the doc spent a half hour with me, following up on other things in my chart from previous visits. I expected it to be a super quick visit since they squeezed me in so quickly. But as long as he had me there, he asked about other things. And this timely and good treatment was all on Medicaid. My year experience on Medicaid has been the opposite of all the horror stories I’d heard about Medicaid.

    This visit, he ordered an abdominal/pelvic CT, my first since my surgery a little over a year ago. He doesn’t overorder the CTs. I got the pre-authorization # on a Thursday afternoon, called an imaging center in my neighborhood (not affiliated with the hospital where all my docs are currently based), the CT was done the next day, Friday afternoon. And by early the next week, my doc and I had the results. (Good. NED)

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

    If “processing the insurance forms costs $58 for every patient encounter”, and you work 250 days, and see 25 patients per day, you will spend a total of $362,500 on “processing insurance forms” (not sure what that means really, but I assume its claims processing). This number makes no sense whatsoever….. Even if your entire overhead is included here (e.g. rent, electricity, malpractice insurance, nurse salary, some of your salary, furniture, medical supplies, etc.), it still doesn’t add up for me.

    If you want people (patients) to choose direct primary care, you need to tell them know how DPC benefits them, not how it benefits the wellbeing of doctors, and in either scenario, you should use good data. Comparing doctors to professional bloggers is a pretty farfetched notion, seeing how practically nobody is a professional blogger. Try something more common, like say, a social worker at a public agency, a teacher, a Walmart cashier, even a nurse…. It’s plain marketing 101.
    Just like there are financial limits on what you would do to make patients happy, there are financial limits on what patients would do to make doctors happy, particularly if they can’t see what’s in it for them.

    And I am writing this as a firm supporter of truly “direct” primary care, including direct fees (or chickens) for direct services.

    • Patient Kit

      Those cost per processing a claim numbers rang exaggerated to me too. Likewise, many patients have 10 or more medical problems? I think the problems we have in our healthcare system are bad enough. Exaggerating only strains credibility about what is being said. I started out open to learning more about DPC but it’s sounding more and more like it’s good financially for doctors but not so good for patients.

    • Barry Lowe

      I’m curious about those numbers, too. I’ve exchanged emails with Dr. Schimpff over the years. I want to see if he’ll chime in on their origin. Very high. But it’s worth pointing out that THAT is Josh’s point–that the way we’ve set up our system to blindly reimburse itself is what’s driven the cost of care to absurd levels. And, while we’re at it, if someone is blindly leading doctors like Josh towards “exaggerated” numbers, shame on them for such. That only veers us away from properly tackling our imperfect situation.

      To paraphrase, agree not to disagree, but agree to solidify those numbers before we debate them further?

    • futuredoc

      The $58 was told to me by a large PCP group that switched to a no insuranace, “pay at the door” practice.” This is what they say they saved per encounter (claims, billing and administration) allowing them to charge a modest fee and still reduce the number of encounters per day. I do not know if they are typical. Look at Concierge Medicine Today where a chart indicates 40% of revenue goes for these functions. Whatever the number in any individual practice, it is time and money that is not going to clinical care.
      The real issue is that PCPs can give outstanding care if they have only a reasonable number of patients under care such that each gets the time needed to be really listened to and so the PCP has time to think without rushing on to the next patient. That’s just about impossible in the current fee for service system. Direct primary care is not the only answer but it is certainly a good answer.
      Stephen Schimpff

      • Patient Kit

        My new personal Plan B for myself and others who can’t afford to go to the doctor, is to study hard at the Google School of Medicine and try healing myself. If I get good at it and don’t hurt myself too badly, maybe I’ll branch out and treat others who make too much money to qualify for Medicaid but not enough to pay for insurance or DPC. In addition to Google Med, I could throw in some magic, herbs and practice sawing off casts without sawing off limbs. Oh sure, I couldn’t call myself Dr Kit and I might risk being burned at the stake. But if we’re going to consider healthcare reforms that leave a lot of people out, somebody will have to step in and fill the need. :-p

        • Arby

          Maybe I will visit you when the single payer national health care locks me out of care because I’m too old and too costly to figure out what is wrong with me and they have outlawed visiting private doctors.

          Sigh. I struggle with your continued misplaced fear of direct care locking people out of getting medical treatment because:

          1. Direct care can’t overtake anything as a national movement without catastrophic insurance coverage, which is where?

          2. We will have single payer in our lifetime. The utopian thought that all will have care then is unrealistic; it will just be rationed differently. And, no, I am not one to expect hundreds of thousands of dollars of care in my last days. I wouldn’t even get a bypass if I needed one. My point being, I am not talking about the extremes, I am talking about being able to see a physician without waiting months because a subtle form of rationing will have to be implemented because everyone can’t be seen for a non-infected, non-diabetic hangnail. If you wish to see government in action look at how the mentally ill are discriminated against. Their care is next to non-existent government funded because they don’t have a large voting block.

          3. After single payer implements it will be a miracle if direct care isn’t outlawed..

          All I ask is to have the tiny ember of direct care grow a little, so people like you can see that it doesn’t cause patient Armageddon, and I can have a physician that I am working with instead of even more of the government or some monolithic corporate entity, before they come and shut it down. Is this too much to ask?

          Note, this comment is from someone raised in abject poverty and working poor now. I assure you the rates for direct routine care quoted on this site elsewhere, are manageable. And, if you are poorer than that there is Medicaid.

        • Dr. Josh, AtlasMD

          So your solution is to “google it” until you think you’re good enough at it to have other people pay you to do it? Would you by chance…charge them directly….

          I guess I would say that I “textbook-ed it” for 12 years….until the state said I earned a license to practice medicine.

          • Patient Kit

            You’re taking me too literally. I was being sarcastic. Maybe you missed my tongue-in-cheek emoticon. Still, I really believe that in your ideal world of a healthcare system dominated by DPC, many people would be left without access to primary care docs (regardless of you being unable to imagine anyone not being able to afford DPC). If DPC became the dominant model for primary care, the already widespread “self-treating movement” would explode. At least, if many of us will be left without access to doctors, we do live in a time in which we all have access to medical information. I’m just trying to plan ahead and have an emergency plan B.

            But my clear and oft stated preference would be for all Americans to have access to doctors. I’ve also said that I fear DPC going the way of dentistry and mental health, two fields of healthcare that are largely direct pay with the result being many Americans going without needed dental and mental health care.

            However, if I must become a neighborhood “witch healer”, I won’t charge for my amateur white magic or uneducated use/misuse of medical info. It would not be my full-time job. But I also won’t just stand by watching people suffer without, at least, trying to help.

            Again, just in case you don’t get my dark sense of humor, I do not in any way equate Google with doctors’ years of medical school and residency and post-residency experience. But if doctors aren’t going to treat us, what are we supposed to do?

          • alicia

            clearly this process The doctor speaks of is merely an option. The key is we hope it does not become illegal because he is operating beyond standard practices. It is nice to have options when govt care or existing care is futile

          • Patient Kit

            I’d have little issue with DPC as a small niche option. But Dr Umbehr talks about it as if he wants it to be a very widespread, dominant model for primary care in the US. And again I ask: why would direct pay primary care be any different for many people than direct pay mental health and direct pay dentistry?

          • Arby

            Mental health care is an issue for the poor/working poor because of government funding for it, not because there are private pay only psychiatrists. Affording dental care is for many an issue not just the dirt poor. But you would be incorrect if you think that this is largely due to dentists being private pay. Only for the most destitute is it a problem and for them we probably could find a solution. For the others, it it because their priorities are all screwed up. They would much prefer to have smart phones, video games, expensive clothes, manicures, rims on their cars that cost more then I spend in a month on food, etc. instead of on dental care.

            I’ll grant you that the poor spend money frivolously to make their pathetic lives a little better, I know I’ve been there, but private pay nor people’s poor spending habits are what made the costs go through the roof and largely unaffordable to anyone without insurance.

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

        I found the chart you mentioned and it just states without citation that “the Direct Primary Care Coalition estimates that payer-related costs add up to 40 cents of every healthcare dollar in a practice”. Couldn’t find where the DPCC said that, but I saw this number before, so I tracked it down to a 2009 article in the Puget Sound Business Journal that gives no rationale for this statement ( http://www.bizjournals.com/seattle/stories/2009/08/17/story2.html?page=all ).
        For the average $70 level 3 visit, this is $28, and I still think it is probably a tad too high, but I guess it depends on how you want to calculate this.
        That large PCP group that gave you the $58 figure was probably a bit too large for its own good, because as I am sure you know, there are really no economies of scale beyond a couple of docs in primary care.

        Either way, my point was that if we are going to advocate for primary care docs, we should not give the opposing parties easy ways to dismiss our arguments. Numbers are important.

        • Patient Kit

          I agree. Part of my former job as a research analyst (social justice issues, not medicine other than health care reform) was to come up with info that my bosses could know was true and accurate (and documented) when they went public with it. Any info that is exaggerated, over-dramatized or just plain inaccurate does give the opposition a means to discredit you and the undecided a reason to wonder about your true agenda.

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

            That’s exactly right. There is so much misinformation floating around now, that people feel compelled to fact-check everything, so we should be careful. Besides, things are bad enough without inflating numbers. As I replied to Dr. D. below (or above), if revenue cycle management was to the tune of 40%, commercial companies that offer these services wouldn’t be “giving it away” for a measly 6% of collections.
            IMHO, the biggest hit is actually taken by the patient, because of all the clerical/computer work that insurance forces on the doc, in lieu of actually interacting with her patients, and this is easily 40% of time spent in a visit. If we present it that way, it may resonate better with a larger audience.

    • Dr. Josh, AtlasMD

      Actually, when you consider that the overhead for most practices is 60-70%, the $58 amount is representative of that overhead.

      see: http://online.wsj.com/news/articles/SB10001424052970204603004577271340816194320

  • ninguem

    Kevin are you on this story?

    http://www.post-gazette.com/news/health/2014/05/26/Some-med-school-grads-fail-to-get-residency/stories/201405260083#ixzz33FTnbKnk

    We are getting to the point where we are graduating more physicians, than we have postgraduate positions to train them.

    We’re just about at the tipping point, right now.

    A medical degree, without residency training, is a useless piece of paper, one that cost the student eight years of life and hard work, and upwards of a quarter-million-dollars debt.

    Right now, it’s 412 medical school graduates unable to find training. Not clear if that’s including the osteopathic graduates or not. If they didn’t count the osteopathic graduates, likely that number is significantly worse.

    In the past, the unmatched students were a couple types. They were bad apples, not bad enough to throw out, they were good enough to graduate, but no one wanted them for various reasons. Some were qualified students, but set their hopes on the very high-end competitive specialties, neurosurgery or plastics or derm, or ortho, and they.were perfectly good, but not good enough.

    There are new schools being opened right now. The established schools are expanding. That “412 unmatched graduates” number is guaranteed to get bigger. Much bigger.

  • buzzkillerjsmith

    1. 90% seems high.

    2. 40 pts/day seems high.

    3. $58 seems high.

    4. Humiliation? You should have seen me at the Senior Prom.

  • Dr. Drake Ramoray

    I agree with the other posters that your figures seem a bit exaggerated. I know my practice isn’t spending $58 per claim, and would napkin math it to no more than about half that. Although I suppose to a degree that depends on what you mean by “claim”. Getting paid for E&M codes and in office procedures doesn’t cost much. I suppose if you added all the time spent on formulary, prior authoriazations, and appeals for imaging often ordered by the doctor you could get to $58, but some clarification is in order.

    In addition I agree it is misleading to suggest that all 24 patients seen in a day have 10 or more problems. I will admit at is a scenario I fear with all this “top of their license” business in an ACO/PCMH scenario for docs working with NPs but this sort of patient schedule isn’t reality for most docs… yet.

    My last bone to pick is your use of the term fee for service and your loose use of it in a negative light. Portions of the NHS are fee for service, Canada’s system is fee for service. In fact just about every country with nationalized healthcare, single payer, you name it, is fee for service. The problem is not fee for service, the problem is the payment/billing mehods of large or profit insurance companies.

    You can run a direct pay practice using a fee for service model. I am working towards one in a specialized field with a la carte pricing that will be lower than private docs who take insurance, and certainly less than the hospital. It will still be fee for service and about as transparent as going to the hardware store.

    The opposite of fee for service has largely been defined, by this doc at least, as pay for performance, which gives third party payors even more power and conveniently absolves them of any financial risk in patient care. It will be the death knell of medicine, especially for the poor and underserved.

    I support your direct pay endeavors, but I find this article exaggerated, misleading, and sloppy and lose with its termoinology and analysis of the evolution of healthcare in the United Stafes an the role that direct care could play in such an environment.

    That being said I will note your Drop Out Club on my list of possibilities for the day that seeing Medicare/Medicaid becomes a condition of licensure. This is being bandied about it at least two states (Mass and VA). Direct pay may not be a longterm solution for docs, especially as more and more become employees of large hospital corporations who will squash direct pay docs like a bug if they become more than a blip on the healthcare radar.

    • John Henry

      Add in denied claims where work done is never paid for by either the carrier or the patient.

      • Dr. Drake Ramoray

        I am aware of denied claims, and as I said for E&M at least we basically don’t have denied claims. Endo doesn’t have many procedures and we dot get denied for thyroid ultrasound, biopsy, or FNA. Even CGMS is near universally paid for type I diabetics. Sure we spend a lot of time on other radiology denials, MRI comes to mind but moving to direct pay doesn’t fix that unless your either gonna get your own MRI machine or think patients will pay upwards of $4000 Defoe an MRI.

        This is why if I go direct pay I will do thyroid only. No point in going direct pay diabetes because you will still have the cost of meds for patients or the hassles from their insurance. Same for advanced imaging for non thyroid problems. Thyroid labs in house ultrasound in house Nuc med. Cheaper than those who take insurance. It can work. But only because it is highly specialized niche care where complete service can be provided at a fairly affordable price without using insurance.

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

          Here’s the thing: if you outsource your billing in its entirety to a third party revenue cycle management company, the going rates are around 6% of collections for primary care and lower for specialists. This includes all the denials and rejections and appeals and crossovers to secondary and posting and collections.
          If you add the time spent on pre-auth in the practice and the time to verify eligibility (this is now all electronic), than you can maybe hit 10% of collections. The only way to go higher is to start adding cost of opportunity lost, and I question that addition, because in a perfect world without insurance you would be spending more time with the patient, not seeing even more people than you do now….

          • Dr. Drake Ramoray

            We are definitely in agreement that his money spent on “claims” is too high.
            Via my math and plan I will make less money going direct pay. That is hardly a consequence for having more time to deal with patients and not have to deal with insurance companies.

          • DeceasedMD1

            I am not sure of the numbers, but point well taken. 10 percent costs just for billing is too high. There is a growing economy for billing companies that make a small fortune out of this. Once again our medical Industrial Complex at work.

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

            Yes, it is too high, and this is only part of the total cost to the patient, because on the other side of the equation, there are payer administrative costs, which are at the very least 15% of premiums and probably a lot more. All in all, we are “throwing away” something around 25 cents on each health care dollar paid to private insurers. Subtract that from our average per capita cost, and voila, we’re in line with those “efficient” European countries…. factor in our inordinate disparities in wealth, and our “outcomes” will probably match too.
            We are being simultaneously robbed, cheated and lied to by CorpMed….

    • Patient Kit

      Re the Drop Out Club, I have a hard time visualizing most docs being happy as employees of hedge funds. That’s probably because I, in general, think very highly of docs.

      • Dr. Drake Ramoray

        As long as I’m not working in corp med, and that comment was a reflection of that. No I wouldn’t be happy as a hedge fund manager.

      • DeceasedMD1

        I suspect you are right. Would be like selling ones soul to the devil. But clearly it is happening and getting out of an unhappy situation for many, they may convince themselves it is the right path to take.
        It is ironic when you hear these talking heads on the news, their answer- I think Obama or someone in his cabinet recently said that we need to encourage more to go into Primary Care. Surely they are not so stupid to realize why they are not. The recent VA scandal showed docs were making around 98K to was it $160 or $170K with terrible work loads. Anyway what was interesting was the director was making more. $190K. Sorry I dont recall all the figures but is it a mystery as to how they can’t retain docs? Also they directly linked the lying about wait times, to pay for performance for admins.
        Seems that although pay for performance is now killing patients, I seriously doubt it will stop. But I digress…

        Seems like doing what is ethical and humanitarian is not rewarded to say the least.

    • DeceasedMD1

      Looks to me like this drop out club is not just converting MD’s to hedge fund managers. They are looking for expertise in medical/science background for a reason. Likely, to pick your brain to use this info to increase their market shares. Not for them to have MD’s trained to be one of them. Perhaps i am overly suspicious, but if you look just at Big Pharma, they pay a fortune (like on Sermo) to pick the brains of doctors to use for their industry which I understand is quite lucrative for them. We are not the consumer any more. We are being bought and sold for the informations that is extremely valuable to the “medical industrial complex.” I am not sure but i don’t trust these guys. What do you think? Can’t even get on the site without signing up.

      • Dr. Drake Ramoray

        If the MBA in corp med our going to treat my medical knowledge as a commodity then rather than work under their rules and regulations, I will either directly market them to patient via direct pay or if that is no longer a possibility then perhaps I will market that knowledge directly to other parties. I sure as he$& didn’t train till my thirties to see widgets on a conveyor belt, which is what insurance driven medicine in this country has become.

      • SarahJ89

        “Perhaps i am overly suspicious”
        I really like that in a person.

        • DeceasedMD1

          LOL. Thank you but it sure gets in the way of blind optimism.

  • SteveCaley

    We must concede that nobody cares to fix it. A brilliant writer pointed out that our American Public School system has been broken for a hundred years while we “search for solutions.” We treat the magnitude of the challenge as though it were absolutely impossible. However, we run holiday theme parks that run perfectly profitably and satisfy the customers. It’s not that we can’t – we won’t.

    • DeceasedMD1

      Exactly. That’s where the values are. entertainment/sports and somewhere education runs at the bottom of the list. Pretty sad it is so devalued. After WWII, teaching was a very respected profession and sought after as a good job.

      • Dr. Drake Ramoray

        It still is if your plastic surgeon, opthalmologist, orthopedist, dermatologist etc

        • DeceasedMD1

          You may be right. But in my neck of the world, seems like business rules.

    • buzzkillerjsmith

      Absolutely. Remember back in the 80s when they sent a teacher into space in a bull@&^% attempt to show how much America appreciates teachers?

      They’d send up a doc if the shuttle program were still around.

      • EmilyAnon

        Christa McAuliffe. Only a sad footnote now.

      • DeceasedMD1

        They don’t need to. They’re killing us off on the ground just fine and it’s a lot cheaper. Ok Buzz that was good. Spilled some coffee on my PC from laughing so hard. I was actually just at a space conference -beats medicine–and it was clear that no ones life was particularly safe. I was reminded of Apollo 1 where the astronauts burned to death on the ground because the hatch wouldn’t open. No one remembers these guys either. They probably would have been the first moonwalkers if they hadn’t been blown up. But point well taken. So nice to feel appreciated, isn’t it?.

        • SarahJ89

          The night before Christa went up there was a bull@&%t piece on the telly purporting to be a history of NASA. Narrated by Burgess Meredith, who consistently mispronounced the name of her hometown in his god-like voice.

          What shocked me was the omission of Gus Grissom and his colleagues from the “history!” How could this be? It wasn’t that long ago at the time. Did these people really think we all had such short memories? Or that we wouldn’t know how to pronounce the name of our state capital? Or, worse yet, we wouldn’t notice the fact NASA had had great trouble getting the previous two or three shuttles safely home? Guess so.

          I told my husband that night “I have a bad feeling about this. These people don’t know what they’re doing.”

          Okay, I really try to avoid getting political but the fact is a close friend of mine is a translator for the US government. He was assigned to translate Reagan’s State of the Nation speech. The centerpiece of that speech was the flight Christa was on. It was a huge political thing for the White House at the time. (Although they got more than they bargained for with Christa. She was an extremely intelligent woman who took full advantage of the opportunity to speak for her profession.)

          Later the White House denied “pressuring” NASA. I have no reason to believe my translator friend was exaggerating in any
          way when he described the political importance of that flight. NASA, which had started out as a bunch of geeky engineers, had clearly been politicized and people, including an unusually fine teacher, paid the price with their lives.

          Christa lived in the next town from mine, went to aerobics with a friend of mine. It’s a rural area. The facts are burned into my head.

          • DeceasedMD1

            Thank you so much Sarah. I am very glad someone else remembers Gus Grissom. Not many do. i am guessing that NASA fixed that problem in the ’6o’s and figured these things couldn’t happen again in their modern age.
            Very sad but your comments political or not were most welcome and really interesting. Any idea why the White House was pressuring NASA and who thought it was safe to send a civilian up there? Reagan was speculated to have been getting dementia while in office. Did his speech sound strange in any way to your friend-although of course he had writers I am sure.

            It was a while ago so did not recall there were problems with getting previous shuttles home. Amazing anyone agreed to go up in the shuttle especially civilians. No wonder that event is burned into your mind. It would be a lot better if Christa was a lot less famous and still taking aerobics with your friend.

          • SteveCaley

            Wonderful point. Given Tom Wolfe’s point in his book, the space program was laid out honestly as an incredibly dangerous enterprise, and test pilots who made their living improvising at Mach 2 were considered good candidates. Even the real top-notch improvisers wound up dead, but not all of them.
            And then, the program became MANAGED. There was still enough there got get Apollo 13 back from WAY out there. Now, we’re hoping to get people into Earth orbit, but we can’t do that so swell no more.
            When America honored ability, test pilots and doctors were the kind of people you could trust your life with. Now-the grey Bureaucratic Pixies rule everything.

          • DeceasedMD1

            Thank you. We clearly think alike. I very much admire these guys. Met the Apollo 13 ground controller Liebergot and astronaut Fred Haise, Richard Gordon and Alan Bean to name a few. Oddly enough, Fred Haise’s comment to me was odd, perhaps not completely truthful, who knows? But he said he never felt his life was at stake. But the whole time he felt horribly disappointed that he was unable to complete the mission. Listening to Liegergot, the ground controller, he was clearly in denial and quite lucky to be here with us.
            What I admired about them was they were not only the best and brightest but overall were extremely humble, Although they are still remembered by many, the new order of social media and app start ups are the new American idols and these guys feel largely forgotten to me. They charge a small fortune for an autograph though.Oh and getting them into earth’s orbit, so right we can’t do that so swell no more! Did not seem terribly important at the time, so why not just leave it to Russians? No worries.

            It is very sad to me as well that ability does not seem to be valued anymore as in doctors and test pilots. Heck the aeronautical engineers I met at the conference, also uber bright and humble are mostly out of jobs and have found niches elsewhere. One told me he left as there was no job stability. No room for rocket scientists anymore either I suppose.

      • SteveCaley

        I had the honor of caring for a relative of Captain Dr. Laurel Clark MD, USN who died in the Columbia disaster on Feb. 1, 2003.

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

      Yes, this is largely our fault – panem et circenses

    • Dr. Josh, AtlasMD

      I agree with you for the most part, but there are pockets of docs that are working to fix it and lots of patients that are demanding a fix. you can see the movement growing at http://www.iwantdirectcare.com

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

    I am not seeing anything that gives me hope, but you never know, things may change….

    • DeceasedMD1

      Are you more aware of any bills being proposed? It’s an election year so nothing will get done anyway.

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

        Not really. There a couple of tech bills pushed by lobbyists of communication companies, but they are going nowhere, and that’s a good thing too :-)

  • Dub

    Interesting, in my area PCPs who sell their practice to the hospitals commonly use the phrase “selling their souls to the devil.”

    • DeceasedMD1

      Seems like there is more than one Devil around Dub.

  • Patient Kit

    Thanks to the discussions here at KMD, I am definitely beginning to get a handle on hospitals being the most expensive place to get medical care. Ironically, being very new to the Medicaid system (1 year, 3 mos), I quickly figured out that teaching hospitals/academic medical centers seemed, by far, to be the best places for me to access good healthcare. It’s been baptism by fire and a real patient education during a time of real personal crisis (layoff > loss of BC insurance > ovarian cancer dx). My main concern was accessing specialists but I get my primary care in the same hospital for now. My specialist care has been excellent. My primary care has been okay. I really don’t have much choice for now. And it has worked well as the safety net it’s supposed to be.

    Re expense to the system, I do what I can. I always go to the outpatient med clinic, never the ER. And when my attending GYN ONC ordered a CT, I had it done outside the hospital. I’m definitely not an over-utilizer just because I have no copay. I’m diligent about my GYN ONC follow up care every 3 months to monitor for recurrence. But I’ve never been one to run to the doctor for little things like sore throats, earaches, colds, flus, minor injuries and I haven’t started going to primary care for that sort of thing now just because I have no copay. I appreciate my docs, but there are many things I’d rather do than go see them.

    I also realize that, living in NYC, is an advantage in this
    situation. There are a lot of docs and a lot of hospitals competing for patients and I haven’t had any problem getting timely appointments.

    I’m certainly not advocating primary care at the hospital for all. But since the care I get there is good and most private practice docs don’t accept Medicaid, what choice is there? It’s far from perfect, but Medicaid saved my life. My worst fear now is becoming uninsured again.