My take: PCP influence, stroke, ECGs/MIs, doctor shortage

1) From a reader: “I don’t understand why, if there is a shortage of primary care physicians, can’t primary care physician dictate rates and policies to the insurers that may want them to see their patients? . . .

. . . Can the physician bill the insurer for the extra paperwork and copies (kind of like an attorney, billing every 6 minutes and 0.25 cents per copy)?”

My take: You are starting to see movement in that direction. An op-ed in the LA Times argued that rejecting insurers may be the future for primary care.

Insurance shields patients from the true cost of care. Patients generally are reluctant to pay more than the $20 co-pay. If a doctor went cash-only, they are gambling that patients are willing to pay for the true cost of the visit. Sometimes it works if you live in an affluent area. However if it doesn’t, you’re left with no patients and an empty, bankrupt practice.

If all generalists left en masse (as an increasing number are doing with Medicare), there will be more leverage to dictate to the insurers. However, there are still a sizable number of doctors who prefer the guaranteed, but decreasing, revenue of insured patients. Until this group is convinced to reject insurers, we will continue to be slaves to the current system.

Although you can’t bill strictly for paperwork – because insurers only pay for face to face visits – there is movement towards getting compensated for administrative tasks. Some are charging patients directly. Others bring in the patient for an office visit to fill out the necessary forms.

2) A cardiologist is sued for performing a cardiac catheterization that possibly led to a stroke.

My take: The case was settled, so we don’t know whether the stroke was a direct complication from the catheterization.

However, this should serve as a warning to patients that the more invasive the test, the bigger the risk of complications. More testing does not always equate to better medicine. In fact, the Dartmouth Atlas group does excellent research showing that more intensive care led to worse outcomes. and a greater degree of medical errors.

3) The NHS is proposing using ECGs to help with telephone triage of chest pain patients.

My take: Stunningly asinine. ECGs are not nearly sensitive enough to diagnose heart attacks. There will be a proportion of patients who will have MIs despite having a “normal” ECG and told not to go to the ED. This is going to open up the malpractice floodgates.

4) There is not a doctor shortage, but a primary care shortage.

My take: Building new medical schools won’t solve the problem. This will simply produce more doctors who will continue gravitating to specialties.

The answer lies in giving current students incentives to enter primary care. Two solutions I have proposed, forgiving debt for those who choose primary care and reconciling the disparity between generalist and specialist salaries, seem to be getting some mainstream media attention.

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