How to stop losing primary care physicians to burnout

Here’s a central difficulty of the Affordable Care Act: If everyone has access to health insurance, then everyone has access to all the medical care they need. Curing sickness and preventing death costs a lot, and society can go broke providing costly medical care to everyone. Society saves money and lives when everyone sees a primary care doctor who works to keep people well.

But we don’t and won’t have enough primary care providers in the United States. We’re already facing a shortage. The Affordable Care Act is only going to make it worse.

There are many people thinking about how to build the future health care workforce we need to keep Americans healthy, myself included. How do we train more primary care providers? How do we encourage them to work in the communities where their services are needed most?

The National Health Service Corps is one answer, and the president is banking on it through a proposed $3.5 billion expansion through 2020, increasing the number of primary care providers involved in the program from 9000 to 15,000.

The next critical step becomes this: Once we have recruited and trained these health care professionals committed to providing primary care in underserved communities, how do we get them to stay in the profession and places where they are needed most?

I went into medical school knowing I was going to do primary care. I knew I would care for the underserved. I had a scholarship from the federal government saying it was so — I had successfully applied for and received a National Health Service Corps scholarship. For each year of medical school the American people paid for, I would complete a payback year of doctoring in an underserved community, providing the cost-saving care people needed to stay well. A doctor to the community, saving money for society.

Today I am a family physician working in a community health center on Chicago’s South Side. In the federally qualified health center where I work, we have some old-timers  – people who have been there for ten years or more, who have found their niche and stay with community medicine.

We have many more new graduates — NHSC scholars doing their payback, or NHSC loan-repayors who get significant dollars to pay back school loans. These NHSC-sponsored physicians come and go. Burnout.

A few years back, my medical director informed me that he assumed I would be leaving as soon as I was done with the NHSC payback. He planned to lose his physicians to burnout. He planned for me to leave. I was a cog in a broken machine to be worn out and replaced as soon as my NHSC contract expired. This was disheartening. In March, I submitted the final paperwork signing off from the NHSC program, and my medical director expressed surprise at my decision to stay.

Why should staying in a community health center be the surprising decision?

There is a two-fold trick to increasing the number of primary care providers in underserved communities. First there is bringing them into the community health centers through financial incentive and professional development programs such as the National Health Service Corps. Second there is ensuring a sustainable practice environment, so that primary care providers work in a positive practice environment and choose to stay in the communities that need them most.

We need policies in place to incentivize the creation of healthy practice environments. There are new incentive programs in place for community health centers to become patient-centered medical homes, with extra points awarded for implementing practices that optimize patient care.

We need new incentive programs for community health centers to become provider-centered medical practices, with extra points awarded for implementing systems that ensure input from all who are directly involved in patient care to optimize patient care delivery in their center.

The first step could be as simple as pay community health centers a $10,000 bonus for each physician who signs on to stay after the end of their NHSC contract. This external incentive could drive practices to think about what they need to do to retain their physicians, instead of automatically planning to lose them and replace them with a new set. Funding could be made available to study the management practices of the most effective community health centers, who retain their practitioners and provide outstanding care, then scale those practices nationally.

As a nation, we can’t continue to invest in building a primary care provider workforce only to lose us to burnout. We need to find and implement successful strategies for provider engagement and empowerment, making health care providers equal partners with community health center administration in the provision of quality, affordable, accessible health care for all Americans.

Kohar Jones is a family physician who blogs at Prevention Not Prescription.

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  • Dr. Drake Ramoray

    =================================================
    “The first step could be as simple as pay community health centers a $10,000 bonus for each physician who signs on to stay after the end of their NHSC contract.”
    ===================================================

    This won’t work. I received a sign on bonus at my corp med job that was 4x this much. Miserable place to work. I still left, early actually and had to pay some of it back

    .

    =====================================================
    “We need new incentive programs for community health centers to become provider-centered medical practices, with extra points awarded for implementing systems that ensure input from all who are directly involved in patient care to optimize patient care delivery in their center.”
    ======================================================

    Actually, I think that PCMH/ACO and especially pay for performance metrics that go with it (Why join this practice model if you think you won’t be graded on how you do) will actually make these underserved areas even less desirable.

    http://www.nytimes.com/2014/04/28/us/politics/health-laws-pay-policy-is-skewed-panel-finds.html?_r=1

    This article reads well, and on the surface sounds good, but well quite frankly I think your solutions won’t work.

    • ninguem

      Drake, the community health centers are, in fact, highly motivated to make your life miserable. They want to drive you out.

      This creates a continuing crisis and a continuing need for government intervention.

      A close friend of mine, classmate, he was in a small town rural health center for payback time for medical school support. He realized after a while, he liked the place, and the townies liked him. His wife and kids liked the town. It should have been perfect.

      “Why don’t you stay there, then?”

      “No, the public health people will run me out of town.”

      The health center was grossly top-heavy with administration, basically one administrator per doctor. They could have run all the primary care docs in the county with one administrator.

      In a private setting, of course.

      Try to take a vacation, ask another doc to cover. Triplicate forms, administrative approval. Basically the runaround to justify their administrative bloat.

      The last thing they want is a doc to set-up there privately. If you had set-up there, it would be the end of their gravy train.

      And in small towns, healthcare is the major employer.

      So, yes, not surprised that you were miserable, the people running places like that make it their mission in life to make you miserable.

      • KoharJones

        That’s a crazy ratio of admin:doctor.
        Less admin telling doctors what to do, and more physicians being informed of the external factors driving payments, and allowing doctors to regulate ourselves– ensuring quality improvement processes and implementing systems that make sense for our environments.

      • SteveCaley

        IMHO, this comment uncovers the disease in all its glory. The way that healthcare in America has been sculpted over the years gives NO moral duty to execute efficient delivery of care.
        The vast bloating of costs comes largely from paying the salaries – and of course, healthcare benefits – of the sky-high pancake of administrative nuisance. They keep their jobs by making people believe that doctors are criminals, grifters and Medi-Thieves, and that all doctors need the administrative ankle-bracelet to keep from wantonly offending.
        A community that distrusts its doctors is headed for doom. There is no fancy-fix that will reverse that prejudice.
        Many people of color feel the same mistrust towards the police, I hear. The police are not there to make things fair and safe – they’re there to justify their existence.
        There is a toxic myth in America that jobs = prosperity, whether the jobs are contributory, or worthless. It’s the same myth that Marx had about labor = productivity. Worthless labor adds no production to the economy; neither does full employment at worthless and damaging jobs.
        The bottom line is – there are more people making money off the status quo, than there are those who wish to reform it – and the majority of the profitmakers add nothing to the quality of care, and there is no moral conscience in the system to structure it otherwise.
        Reform will invevitably benefit the boondogglers – they are the ones with the time and power (and not seeing patients) to connive a phony fix.
        I have no suggestion of how to stop this.

        • DeceasedMD1

          The term economists use for this is ‘rent seeking”. And you are not even an economist! But beautifully said. I read the book by Joseph Stiglitz (a well known economist) who said that he could write a whole book just about rent seeking. itself. But there are so many examples of jobs and products that are over valued or have absolutely no value that are draining us all.I also have no idea how to combat this. Perhaps Big Pharma will find a cure for it one day……

          • SteveCaley

            I recommend the brief note by the poet Shelley, “Ozymandias.” That is the eternal and inevitable cure, as all bleeding eventually stops.

          • DeceasedMD1

            perfect poem for the current times. I did not know you had a website. Thanks for the link. I hope you publish here too. I love your writing. You are a sage but with a twist of fabulous humor. Maybe you could take over Steven Colbert’s job when he leaves and make it your own.

    • buzzkillersmith

      Nice NYT article.

      Government-appointed expert panel: Many, perhaps most, medical outcomes in persons with certain demographic characteristics or socioeconomic characteristics or habits are almost completely determined by those and not by the medical care that is provided to them. Moreover, physicians should not be held fully responsible for outcomes over which they have little control.

      Government: Oh yes they should be held accountable because… Uh, we said so.

      • Dr. Drake Ramoray

        A real world example of why I tell people that if they seriously want to even discuss single payer, collective bargaining rights have to be on the table. For now I will continue my direct pay practice plans.

        • Patient Kit

          If we ever get to a single payer system in my lifetime, I totally support doctors’ right to collectively bargain. Are doctors unionized in other countries?

          • Dr. Drake Ramoray

            Yes almost universally. They are also all fee for service. Only in the US can we not collectively bargain and moving to a non-fee for service system. That is why, as I have posted previously, have overseas jobs on my radar.

      • Arby

        “Moreover, physicians should not be held fully responsible for outcomes over which they have little control.”

        Exactly.

      • KoharJones

        Amen on the holding-doctors-responsible-for-factors-over-which-we-have-no-control!

    • KoharJones

      Great NYTimes article! Health law skews pay for physician performance based on populations. As we think about population health management, we need to figure out how to separate quality of medical care from underlying health status of different populations. Social factors of health vs medical factors of health.
      Maybe shift some of our medical system dollars to caring for the social determinants of health.
      In terms of incentivizing health care systems to prevent primary care provider burnout–my proposal would be to directly pay the health center for each NHSC physician who stays past their contract ending.
      Better yet, identify then pay for the adoption of best systems of care to ensure physician input to prevent burnout.
      Paying SYSTEMS to retain physicians, rather than paying physicians to stay.

      • Dr. Drake Ramoray

        Reimbursing facilities based on physician retention and utilizing physician input on work environments as the main drivers of obtaining that retention are both concepts that I could get behind within the framework that you describe.

        That being said just reducing the complexity of our payment formula, removing red tape for small independent practices, and generally increase the possibility of small independent practices to thrive would go a long way to improve rural and under served areas. I grew up in a small town, live in a relatively small town, and plan to die in a small town (if not a rural house outside any town limits) and there are those of out here who really desire to practice in this sort of setting, but the deck is currently stacked against us (exponentially worse if we want to still be our own bosses). I imagine this is equally true for a colleague or two of mine who I know who practice in some inner city places that would give the average physician some serious pause. We are out there but the current healthcare system is working against us, not with us and shows no signs of improving in the foreseeable future. (Apologies for typos, on my phone).

  • Patient Kit

    I like a lot of your ideas but a few comments:

    (1) Access to insurance does not necessarily equal access to healthcare. At the same time, in our current system, absence of insurance does often equal no access to healthcare.

    (2). While I agree that preventative care is a good thing, I think a lot of people will still only go to the doctor when they are sick.

    (3). I don’t know that much about the National Health Services Corps but if it is substantially subsidizing medical education for primary care docs, it sounds like a good thing. Increasing participants from 9000 to 15,000 also a good thing. Is this the same program that TV show “Northern Exposure” portrayed with a NYC primary care doc practicing in rural Alaska in exchange for his scholarship/subsidy? I’m all for increasing subsidies for medical education in this country.

    (4). I love the idea of incentive bonuses for creating work environments that retain primary care docs and make them happy.

    Hopefully, we all have the same goal going forward — to reform our system so that every American has access to affordable, good healthcare instead of expensive, inadequate healthcare. Since our current system is such a dysfunctional mess, I’m all for putting all ideas on the table for discussion until we find something that will work for everybody.

    • KoharJones

      The idea of the National Health Service Corps is exactly like Northern Exposure–except that one was a state program.
      The NHSC is a great program. It does a good job recruiting physicians into primary care and getting them to go to health provider shortage areas.
      It’s just that the NHSC creates incentives for health centers to burn out their physicians, since they are offered a new crop of NHSC doctors each year. That way, instead of paying incremental increases in salary to seasoned providers each year, they can pay a lower base salary to the newbies then prepare to burn them out.
      If the National Health Service Corps/Department of Health and Human Services wants to GROW a corps of primary care providers for the nation, it needs to figure out how to incentivize health systems to hold on to providers instead of viewing us as cogs to wear out and replace on yearly cycles.
      I’m with you in that I’m all for getting the ideas on the table too.
      What would a physician friendly workplace look like?

      • Patient Kit

        I loved Northern Exposure. One of my favorite TV shows ever. I didn’t realize that the NHSC was so active and, apparently, expanding to subsidize more primary care docs’ education. I agree that there needs to be incentives to keep those docs rather than chew them up, spit them out and replace them regularly. I hope that issue is being addressed. A little long term, big picture thinking rather than the usual short term penny pinching would be nice.

  • Patient Kit

    Great point about residency programs. I would bet that the vast majority of Americans do not know that their taxes pay for medical residency programs. I didn’t know that until I started reading here at KMD. I’m all for extending subsidies for medical education to med school. Increase the pool to include all those people who would love to be doctors and who would be good doctors but don’t because of the cost of the education. Get rid of the major personal debt issue that always comes up when doctors start talking about needing to be paid more.

    • Dr. Drake Ramoray

      This may “fix” the cost of education but doesn’t change that you can make 3-4x much pretty easily with only a few years of extra training an avoid a lot of the hassles and red tape of primary care to boot by simply specializing.

      The answer is simple. As long as proceduralists make much more than primary care or cognitive specialists there will be a shortage of the cognitive types.

      Great article on Kevinmd about Infectious disease specialists (Endo ranks just barely above them) and how little they are paid relative to their colleagues. Specialists don’t want I be paid less (I wouldn’t either if I was in a high paying speciality) and insurance companies don’t want to pay primary care more (Medicare has bumped EM rates for PCPs but not nearly enough to make up the gap).

      There is no political or cultural will to fix the problem that has a rather simple solution of less hassles and better pay for primary care. As I have pointed out in the NYT article (not exactly the bastion of anti-government sentiment) the current plans being implemented will likely make things worse.

      It’s hard to find a good ID doc, or Endo for that matter, but when you do they usually love their field. Why else would we choose to do something that pays so much less?

      • Patient Kit

        No doubt about it. We, as a culture do seem to value specialists more than primary care and that is reflected in the pay differential. It’s kind of like when people go to a ball game, they value a home run so much more than a good double play or a great catch on the warning track. I love a good home run but I love good defense just as much. And you can’t beat watching your pitcher pitch a no-hitter or a perfect game. An even worse reflection of what our culture values is that A-Rod is paid way more than any doc, primary care or specialist. (Sorry for all the baseball analogies, but my nephew just pitched his first Little League bases loaded save this past weekend.)

        I do think more subsidizing of medical education for primary care docs is a step in the right direction though. There have to be some people out there who just really want to practice primary care, who really don’t want to be surgeons or other specialists. If their education is largely paid for for them, theoretically, it doesn’t have to be first and foremost about making as much money as specialists, does it? Or will that pissing contest always be a factor? Would making a comfortable living and getting much more respect ever be enough? Or does primary care have to be paid as much as specialists for primary care docs to be happy? Was there always this pay difference? If not, when did the gap start to widen?

        • Dr. Drake Ramoray

          What subsidizing those for primary discounts is that lots of students go into medical school with the goal of doing primary care but then when they see what it is like they change their mind and specialize.

          • Patient Kit

            So, if you had to choose, what do you think is more important to change in primary care to make it more attractive to doctors — the money or the working conditions? Students must know going in about the pay difference, right? And they still want to do it when they start? So, is it the working conditions that become the ultimate deal breaker?

          • Dr. Drake Ramoray

            I find the working conditions the biggest issue. Working towards being completely debt free. I am playing the long game to develop a low cost direct pay practice. If I’m happy, my patients are happy, I plan to stay that way even if my income is cut in half. My only real regret is this path forces me to drop diabetes as it has the most hassles (formulary and otherwise).

          • Patient Kit

            I feel that way about work too — that the working conditions and fulfillment of doing meaningful work is more important than more money, which is why I’ve spent most of my adult life working in the nonprofit sector. That said, we all rightfully want to be paid fairly and enough so that we can concentrate on that meaningful work without worrying constantly about money.

            I sincerely hope you find your way to being happy as a doctor, DrFriend.

            In this particular moment, what would make me, if not happy, way less stressed, is to not be waiting simultaneously to find out: (a) the results of my latest CT scan and blood tests to see whether my cancer has recurred and (b) whether I will be covered by any health insurance next month.

          • http://www.thepatientdoc.com The Patient Doc

            I am primary care, and if I had the choice to do it again I would still do primary care. But. I definitely think that we need better work environments, and more respect for the work we do. More money would be nice too, considering the amount of debt I have, but really it’s more of the working conditions that need to change. I’ll admit I’ve considered specializing into sleep medicine to make more money, but we need more PCPs and I truly enjoy having a long term relationship with patients.

          • Patient Kit

            It’s refreshing to hear from a primary care doc here who actually does want to stay in primary care. I hope you get the better working conditions and respect that you deserve. There are a lot of us patients out here who do respect you and value the work you do very much. Patients and docs really do need to stay on the same side in this fight.

          • KoharJones

            Agree! I want to stay in primary care, I like the work, and find it very satisfying to keep people healthy and care for them when they are sick, and see families grow and change over time.
            And I want to make sure that EVERYONE has access to quality affordable health care–hence my desire to figure out how to make community health centers work, since we will remain the safety net for the uninsured who can’t provide direct-pay for medical care

        • KoharJones

          Fun metaphor, congrats to your nephew!

  • NewMexicoRam

    In other words:
    “Get the gov-mint to pay extra to the docs.”
    Passing the buck once again.

    • Patient Kit

      Who do you think should pay primary care docs more? Each individual patient? If so, what would you do with patients who can’t pay you more? We do fund our government heavily by paying our taxes. I’d like more of my taxes to be spent on better healthcare, one way or the other. Subsidized medical education. Higher reimbursement rates from Medicare and Medicaid. Fair salaries to all docs in a single payer system. Something.

      Would you take the government completely out of healthcare? And take insurance out of healthcare? And employers out? Why not just make healthcare a commodity that only people with money can afford? Seriously. If not from government, insurance or employers, where do you imagine all the money you want to be paid to be coming from? Should healthcare be considered a luxury and, if we can’t afford it, we don’t get it. Every man for himself?

      • NewMexicoRam

        We’ve gone through this with each other before. I thought you said we would just have to agree to disagree. To make it simple, yes, I think patients need to be more personally responsible. Americans aren’t immune from the eventual consequences of irresponsible spending and it will come to roost someday, probably with our grandkids. Doesn’t that make you feel so grand?

        • Patient Kit

          You are correct that we are one patient and one doctor who apparently have zero common ground (except, I think, for malpractice). I apologize for forgetting that. I guess we really have nothing to talk about. But if you think our entire healthcare system should eliminate government, insurance and employer involvement and be paid for entirely by individual patients (preferably in cash) you should know that we are never going to let that happen in this country. Won’t make this mistake again, I promise.

          • NewMexicoRam

            You used a form of “entire” twice in your response. That is a word I never have used in our discussions, so I don’t see why you are labeling my replies as such. I would say, more accurately, that patients need to “share” in the direct cost to the providers. Co-pays, in other words.

          • Patient Kit

            I apologize for using the word “entire”. As a personal rule, I usually try not to use absolutist, purist, black & white words like “entire”, “always” or “never”. Sometimes I stray from that when I’m highly emotional about something, as I often am about healthcare.

            That said, I guess I really don’t understand what your ideal model would be for our healthcare system. As a patient, I feel I already do pay plenty into our healthcare system via taxes and insurance. I don’t think most patients are getting any free ride with no personal or financial responsibility. When you say “copay”, who would I be copaying with? Doctors instead of insurance? And my taxes would be cut dramatically? Except patients’ taxes and insurance costs wouldn’t go down if your direct pay model only applies to primary care docs. You’re not advocating direct pay for specialists or hospitals, are you? So, we still need a way to pay for that.

          • NewMexicoRam

            What I’m saying is you can’t expect doctors to be able to keep thier costs as low as possilbe forever. Eventually, knowing that the government will not pay doctors at rates that will keep up with inflation, there will be tremoundous pressure to allow doctors to charge patients the difference in what Medicare/Medicaid will pay and what the costs to provide the service is. Hospitals have their own tricks which need better oversight.

          • Patient Kit

            I’ve never disputed that PCPs should be paid more or that you do very valuable work. However, it will be tough to get the difference from Medicaid patients. You have to be very cash poor to qualify for Medicaid. What would happen if Medicaid patients had to start paying the balance of your bill less the little bit Medicaid pays? Those patients would just stop coming to you. They (we) would have no choice. We simply don’t have the money to pay most of your bill. If we had that money, we wouldn’t qualify for Medicaid. Do you know how little you can have to qualify for Medicaid?

            Medicare is a different story since Americans at every economic level are eligible for Medicare at 65. We could cut those above a certain economic class off of Medicare and shift some of that money to higher reimbursements to PCPs. I’m all for better scrutiny of hospital bills. Disallow the apparent rampant overuse of facility fees and shift that money to PCPs. But trying
            to squeeze that money out of poor people may seem like the easiest way to you, except that we don’t have any money to squeeze out. We’d just have to stop going to doctors.

            I do see your dilemma. Do you see mine?

          • NewMexicoRam

            Yes, but you’re not the one having to work for less and less. Sorry, but Social Security payments have increased more than Medicare payments to doctors over the last 14 years.
            Think of it this way:
            Food stamps pay 100% of the grocers’ cost for the food provided. Taxes cover that. What if the government decided that instead of slowing the amount paid toward the food stamp program, they would require the grocers to provide free food. In other words, for $50 in food stamps, the grocer has to provide $55 in food. And the next year $60 worth, and so on. At first the gorocers would shift the cost by charging more to others, but eventually…….
            I hope you see the problem. By the way, have you written a letter to your congressperson requesting higher taxes to help improve doctors fee? Because if you haven’t, I can see that eventually you expect doctors to work for free.

          • Patient Kit

            As soon as I’m done fighting for my life, whichever way that goes, I’ll move better pay for you higher in my agenda list, right up there with good affordable healthcare for all (which I care passionately about), even if I have to fight for you from beyond the grave.

            I do not expect doctors to work for free. But poor folks are not your best hope of getting that money you seek. BTW, before my lay off, I worked for many years for less and less. The last year, the last 50 of us still there were doing the work that 200 did 2 years earlier. We were routinely being thanked for giving 500% which was always followed by telling us that they needed 1000% from us. That and we should be grateful that we still had jobs — until finally we didn’t. But I’m not a doctor, so how could I know what it’s like to be asked to do more and more for less and less?

            I didn’t want to believe it but the people who say empathy is dead may be right.

      • MikeWB

        How much do you pay in taxes?

  • NewMexicoRam

    I can’t stop laughing! The government (Medicare) may pay the teaching hospital $100,000 per resident-in-training, but the resident only sees about $40,000 of that. And working 60-80 hours per week for it.

    • Patient Kit

      What percentage of it goes to residents as take home pay and what percentage goes to the hospitals to run teaching programs, does not negate the fact that that $100,000 all comes from tax payers (aka the government). Would you like the government to stop funding residency programs completely? Or do you just want residents to get a bigger cut of it? Doesn’t some of that money go to attending docs who are teaching residents? Or are you saying the hospital takes that money as pure profit for themselves? I know you and I don’t agree on a lot but I’m sincerely trying to understand where you are coming from with your anti-government stance?

      • NewMexicoRam

        What I’m saying is the docs don’t see all that money. Cassie R made it appear that the residents were paid $100,000 per year. No, they are paid less than a worker on the auto assembly line.

        • Patient Kit

          I thought Cassie was clear that part of that $100,000 a year goes to the resident’s salary and part goes to the teaching hospital. But regardless of how you and I each read Cassie’s comment, it is a fact that that entire $100,000 comes from tax payers. $100,000 per resident per year. That’s a lot of tax money, no matter how it is split between residents and hospitals. Therefore, residency programs are government funded. So, if you want government to get out of healthcare elsewhere (Medicaid, Medicare, ACA) shouldn’t government also stop funding residency programs too?

      • DrTWillett

        I have actually long wondered where the money goes. I went to a private med school (no other choice) and trained in the same system as a resident. Finally worked 2 years as an attending in primary care. The med school paid none of us to teach or precept. It had very little money to offer the docs who ran the various programs. We had a couple of admin assistants who likely didn’t get any more than the residents who managed the rotating med students and the residents. 40K+ a year for 4 years and whatever the government subsidy was for my salary went somewhere, but I had not idea where! It certainly was not the teachers! Oh, and the poor fellows… as resident work hours get cut back, the attendings and the fellows pick up the slack, but fellows get paid little more than the residents.

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

    I actually don’t think the Affordable Care Act will make the shortage of primary care physicians worse. It will make the shortage of PCPs serving Medicaid patients worse, but it will create a surplus of PCPs serving the commercially insured population.
    Why? Because commercial insurance, especially the “affordable” kind comes with high deductibles, so most working folks won’t be able to afford primary care anymore (other than the useless free preventive care screenings). So, as the ACA effects ripple through the employer insurance market, lots of PCPs will see their volume of commercial payers decrease, and others will find themselves out of most narrowly structured networks. Maybe some will join a Community Health Center. Maybe not.

    • Patient Kit

      I agree that many patients with high deductible insurance will go to the doctor as infrequently as possible, only when absolutely necessary and often potentially too late, especially to primary care. The seriously ill will go too late and the truly healthy will stay away from primary care completely until something goes very wrong.

      If the idea is to curb Americans’ appetite for unnecessary visits to the doctor (everyone’s fave thing to do on an afternoon away from work!) and save/make payers money, when patients routinely start showing up at the doctor only once their disease is more advanced and expensive to treat instead of earlier when it could have been prevented or treated less expensively, then payers will get to learn what “be careful what you wish for” means.

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

        Lots of people will get hurt in this process, and I am not even sure if the lessons learned by insurers will be to let people get care when they need it… or maybe just label the too-late care as low-value and get rid of it at that point….

        • Patient Kit

          Sigh. I predict higher suicide rates for all. :-(

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

            I know it’s not funny, but it made me laugh… :-)

          • Patient Kit

            Living with such a disheartening healthcare system and being forced to live in constant fear breeds dark dark humor. I swear, if I didn’t have a good sense of humor, I’d be dead already.

          • Dr. Drake Ramoray

            This seems to be true for doctors and patients alike these days.

          • Patient Kit

            Definitely. I don’t understand how humorless people survive in this world.

    • ninguem

      The only possible advantage of primary care in the scenario you describe, would be if patients see an advantage to having multiple services under one roof…….or more to the point, between two ears.

      As opposed to going to the cardiologist for ordinary high blood pressure, who then refers to endocrinology for the hypothyroidism, who in turn refers to GYN for a routine PAP, that sort of thing.

      • Patient Kit

        I think that’s a pretty big hurdle for primary care. I would bet that many patients would give up their primary care docs before they’d give up their specialists, especially since many of us currently have good doctor-patient relationships with our specialists but minimal superficial relationships with our PCPs. I definitely don’t foresee a lot of women gladly getting their GYN care from their PCPs.

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

        I think people understand the advantage, but having a personal physician is going to become a luxury most people can’t afford. Longitudinal “continuity” will be maintained by computers. Pediatrics may be the exception.
        Medicare/caid patients will have it better for a while, until the public payers figure out how to apply the commercial model to their members.
        I wrote here a while ago that primary care docs will have basically 3 options in our glorious future: be personal physicians to those who can and are willing to pay for it; be managers of large volume factories manned by non-physicians; or become specialists at Comprehensive Care (i.e. small panels of very sick people with multiple conditions). The last two could probably be combined somehow.

  • http://www.thehappymd.com/ Dike Drummond MD

    FQHC’s often have high turnover and financial incentives will not change that. What is missing is the desire and expertise to create the physician friendly workplace you are describing. You are talking about culture, not compensation.

    Paying off their loans gets them to show up. Giving them $10K won’t get them to stay. Think about this for a moment.

    If you have people in your site who have been there 10 years or more, they can tell you (and teach you) how to create a practice environment where people stick long term. If your site has collaborative leadership – administration and physicians – who care about the physicians and staff as much as they do the patients, you can create the environment you seek. Not because they are paid to do so, but because it is the right thing to do, a sign of quality leadership and ultimately more profitable in the years ahead.

    It is also important to equip your physicians and staff with a full array of proactive burnout prevention tools and training. This is a high risk group for burnout, in part because of a patient population that is riddled with multifactorial treatment challenges. Don’t write off burnout when it happens as inevitable, be proactive in preventing it.

    This is another place where culture makes a huge difference. When your culture has people saying “we have each other’s back” … you are headed in the right direction.

    My two cents,

    Dike
    Dike Drummond MD

    • Dr. Drake Ramoray

      “If your site has collaborative leadership – administration and physicians – who care about the physicians and staff as much as they do the patients, you can create the environment you seek.”

      You mean like how the VA in Arizone cares about it’s patients?

      http://www.cnn.com/2014/04/23/health/veterans-dying-health-care-delays/

      Par for the course for my previous VA experiences while in training. I, like Ninguem, question the desire to make these facilities (yes I know this author is not writing about the VA) to improve the working conditions in the first place. Throwing on a $10,000 band aid and write a good sounding article is much easier.

      Dike, your suggestions are excellent ones, but I don’ think the administrators are listening

      • ninguem

        In rural areas, healthcare is often the only decent place to work with a good wage and benefits.

        The FQHC’s, and rural hospitals are often the only decent employer. They’re jobs machines.

        I’ve seen rural hospitals where docs covering multiple facilities were actually ashamed to work there, They did anything they could to steer patients away for their own safety.

        The official claim is the rural area needs the access because of transportation……something that made sense before the invention of the automobile.

        That FQHC rural administrator would be bagging groceries were it not for that center. They know full well if the doc goes private, that administrator job would disappear.

        So they fight tooth and nail to make sure that their job remains secure.

        On more than one occasion, different parts of the country, docs paying back service debt say the same thing. The administrators DELIBERATELY work to drive them out.

        Remember as well, the tactics used to drive out that doc can involve targeting the doc as “disruptive” or other trumped-up charges.

        So the doctor is not just driven out of town, the doc could be ruined for life.

        You want the docs to work rural?

        Pay them.

        It really is that simple.

        I say that, because the money is being paid.

        It just goes to administrators and staffing bloat.

        Start by paying rural practice at city rates. There is one pay scale for Big City, there is another, lower, rate for rural areas in the same state. Pay the same rate.

        They won’t because the thought that a family doctor might earn a dollar strikes fear in their hearts.

      • ninguem

        And that’s across the board Drake.

        All the things you hear about how great the VA is…….all lies.

        Not mistaken. Not misunderstanding.

        They’re lying.

        They kept two sets of books. They knew full well what they were doing.

    • ninguem

      Dike I have yet to see a FQHC like that.

    • KoharJones

      Yes! You beautifully describe the problem I am grappling with–how to grow the desire and expertise (among admin? among staff?) to create a provider friendly workplace.
      What would you suggest to do to shift the workplace culture to create a place that nurtures providers and heals patients?
      Giving the $10,000 incentive to the CENTER after a physician stays on was my simple, one-lever attempt to try to create an external incentive for the system to change the workplace culture to prevent physician burnout. That may begin to nudge the dial. And I agree we need more comprehensive approaches.
      How would you begin to shift the workplace culture to prevent provider burnout?

  • buzzkillersmith

    Here’s a summary of this comment thread.

    Doctors: Based on our experience, doing this for years, we can tell you that primary care in particular and medicine in general is a tough gig. Often a crappy job. Crappier than many know.

    Non-doctors: Oh no it isn’t.

    Comical.

    • Patient Kit

      Who, in this thread, claimed that medicine isn’t a tough gig? What non-doctors in this thread claimed that being a doctor is easy?

      • NewMexicoRam

        It must not be tough enough for you to acknowledge that doctors should have the right to charge the shortfalls to the patient that the Medi plans don’t cover.

        • Patient Kit

          I have acknowledged that PCPs should be paid better by government and private insurance. I am not one of those people who demonizes doctors. I am not your enemy. But your insistence that the best way to get more money (the balance you seek) is to get it directly in cash from Medicaid patients has me thinking that you really have no clue how poor you have to be to qualify for Medicaid. How would you squeeze this money out the poorest people in the country, people with zero income? What money?

          You want to talk math? I’ll use myself as an example. Since my lay off and the end of my unemployment benefits, I have zero income. I’ve spent my life savings keeping a roof over my head during this cancer crisis (because treatment for ovarian cancer couldn’t be delayed until I found a new job and stabilized financially)., So, now I have zero savings and zero income and am on the verge of losing my home (which I rent, not own) and becoming homeless.

          In order to qualify for Medicaid, the only insurance that would cover me for treatment of a pre-existing cancer, I couldn’t work for a while. When I even start to work part-time temp with no benefits, I will be cut off from Medicaid. I am planning to do that to try to keep a roof over my head. My choice is: Do I want shelter or medical care? Oh, and while covered by Medicaid, I have been receiving $200/mo in food stamps and $169/mo in cash to cover the cost of living in NYC. I would love to see you try to squeeze the balance of your bill from that $169/mo free ride gravy train. Better yet, I’d love to see you try to live on $169 a month.

          Seriously, I understand your dilemma. But do you understand mine? Your desire to squeeze more cash out of Medicaid patients makes me think you don’t have a clue. There is no cash to squeeze from us.

          • Arby

            I hope you get a good disability lawyer. You can work part-time on disability.

            For welfare, the rewards are in the wrong place and those that want to work to get back on their feet are penalized. And, now they have to pay for non-care under the ACA. And, people wonder why disability has exploded.

          • NewMexicoRam

            Again, you keep forgetting that requesting the right to balance bill would also give me the freedom NOT to balance bill, which would take care of situations like yours.

          • Patient Kit

            Bottom line: I guess I wouldn’t trust you to do that, especially when you just said to Margalit above that you don’t really believe that Medicare and Medicaid patients can’t afford to pay you more. When would that financial conversation happen with your patients and how would you decide which ones have to pay the balance of your bill and which ones don’t? Why do you even see Medicaid and Medicare patients? That seems like the easiest answer for you: Just don’t accept Medicaid and Medicare patients. It sounds like you want to accept limited income Medicaid and Medicare patients and somehow turn them into direct pay cash paying patients. I’m sorry, but that’s just not going to work. If you truly believe they have the money to pay, you really are out of touch with what it means to be poor.

          • Arby

            Please keep in mind that not all Medicare patients are poor. I’ve seen plenty who are not and many multiples in casinos. Even among the Medicaid population there is an underground economy. As you said, who can live on the pitiful welfare amounts (unless you have multiples of children) so they don’t.

            The problem is of generalization of your situation to all

          • Arby

            I forgot to mention there is some ridiculous policy about those on disability not getting Medicaid for 2 years. How does that make sense?

            Anyway, I think it is backdated to start of your disability, plus there may be exceptions for cancer treatment. Again, it is best to get a good disability lawyer, plus a good social worker.

          • KoharJones

            I’m so sorry to hear of your tough situation. I wish you didn’t have to juggle economic survival on top of surviving cancer.
            Zero income means zero income, my patients remind me frequently. My mind was blown when I first began. “I’ll need to steal to get the $4 generic,” one uninsured patient said when I tried to give him a blood pressure pill, trying to treat the silent killer.
            He has Medicaid now thanks to ACA expansion. There are still too many people falling through the cracks.
            Good luck to you, I wish you health and housing and stability.

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

          Okay, say you have the “right to charge the shortfalls to the patient”. How is that going to work? Obviously folks on Medicaid and a good amount of those on Medicare won’t be able to pay you. Presumably they won’t come back.
          So why not just stop taking Medicare and Medicaid now? Wouldn’t this achieve the same results for you?

          • NewMexicoRam

            When I’m at 70% Medicare and 10% Medicaid? Guess I’ve have to move.
            Look I was in Haiti in 1980. Even there the mission hospital charged the patients a SMALL amount–and people paid. Haitians are a LOT poorer than anyone I’ve seen in America, so the claim people can’t pay doesn’t really fly. And again, I said in another post that doctors would still retain the right not to charge, or charge only a small amount. I’m just saying give us the freedom so we can charge, and especially those who can afford it.

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

            Yes, there are people on Medicare that can pay, and I’m sure some folks on Medicaid can pay as well, and a minority can probably pay a lot more than just a small amount.
            The problem I am having with this approach is very simple: how are you going to make this work? And remember that it’s not just you; it’s all the other doctors they need to see if they are really sick.
            Is your office manager going to haggle over the price with each patient, every time they come in? Are you ready for people crying and begging at checkout? Will you do a quick means testing before you take a new patient? Ask for IRS returns maybe? Are you going to just put a jar out there and ask people to contribute what they can?

            Wouldn’t it be a lot easier if the government did its job a little bit better? Because that’s the real problem here.

            On some level, I do believe that there should be a way for doctors who want to charge more to be able to do so, and let our beloved market forces decide where the customers go. However, the way I think this should work is that you would opt out of Medicare, charge the patient whatever you want, and the patient would submit the bill to Medicare for partial reimbursement.
            I am pretty sure that a practice with 70% Medicare would go bankrupt as a result of such change, but I wouldn’t mind seeing a pilot or some “innovation” grant to test out the effects of this little experiment. My gut feeling is that we would need to significantly expand the CHC infrastructure as a result….

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

      Are we reading the same thread?

  • Vikas Desai

    what people dont realize is that these Federally qualified centers actually a recieve considerable funding and actually get paid a lot more than a private physician to help the underserved, as usual that money goes towards waste and beuracracy, which ends up leading a low physiican pay and high turnover, pay the physicians in the community more for these patients and not the adminstrators with political ties who run these places.

  • David Austin

    I’m not a doctor, but everything I read is that they have their hands tied by paperwork, bureaucracy and insurance companies. Burnout is increased by the fact that these things are enough to keep anyone going into that field.

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