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Caring

Lamberts The “empowered patient” movement (which I think is a good thing) strives to take the doctor out of the center of care and put the patient at its focus.  The role of doctor is not to be the star of the show, the quarterback, the superhero, but the advocate and helper for the patient to accomplish their goal: health.  Many rightly attack doctor prima donnas who want the exam/operating room to be about them instead of the patient.  This is healthcare, not health performance. They want doctors who care more about the people they treat than they do about money, praise, or status.

I get it.  I get the message that doctors have to adjust to this new age of patient empowerment and patient-centeredness.  I get the fact that making patients wait is a bad thing, and that communication is as essential of a skill as is medical knowledge – remove either one of them and you don’t have care.  I hear the message: doctors should care about patients more than they careabout themselves.  That is what we are paid to do, and that is what we have neglected at our own peril.

So why is it, then, that those of us who try to be patient-centered in our careend up getting penalized?  If the days of the doctor-god are over, then why are we still paying premium dollar for those huge egos?  Why do we pay more for technology than humanity?  When I face the continued threat of declining reimbursement (don’t forget, then next SGR battle will be over a 30% drop in Medicare reimbursement) I feel angry.  I am the point of care, not cost.  I am cheap. I spend my day trying to keep people well, trying to find cheaper medications for them, trying to avoid expensive procedures and consultants.  How am I rewarded for fighting the tide of spending?  With increased expectations, increased fear of the future, and decreased pay.  I see the gratefulness of my patients, and that keeps me from fleeing altogether; but I also face the callous cuts by CMS, the increased micro-management by the insurance industry, and accusations of being a “greedy doctor” for not wanting my pay cut.

Why is this?  Why is a system that is growing more and more expensive seeing cutting my pay as a means to saving money?  Why not focus on the durable medical goods that solicit business from my Medicare patients, suggesting that they can get “free” commodes and scooters?  In the past few weeks I have done three “mobility evaluations” for people who are trying to get scooters.  They have done this in response to the commercials or direct phone calls from the companies that provide these devices.  Beyond that, I have seen a huge increase in the number of ludicrous requests by these companies who prey on innocent and ignorant patients.  They are leeches.  They are bloodletters removing the life-essence from a dying patient. Yet their presence is growing.

Why not focus on the generic drug manufacturers who are still able to charge premium prices for their drugs?  It used to be that when a drug went generic, it got cheap.  For some reason, however, things have gotten far more complicated.  I now need to know which are the “cheap generics” and which are expensive.  I need to remember which medications that were inexpensive have been forced off of the market by more expensive competitors (cough syrups and colchicine, a drug used for gout are two examples of this)?

Why not focus on the hospitals who are buying physician groups so they can order more tests in their facilities?  The pendulum has swung now back to the hospital-owned physician groups, with doctors fleeing the fear of SGR and other reimbursement debacles for the “safety” of a salary from a hospital.  The problem with this is that the hospitals are huge consumers of healthcare resources.  Hospitals hire doctors because doctors can send them “business.”  In case you forgot, “business” is another word for “spending.”  Hospitals are things patients should avoid, but doctors are hired to be a turnstile into the land of medical spending.  I have lived in both worlds, and I am far more patient-focused and cost-conscious than I ever was when owned by a hospital.

We have a bunch of hands being plunged into the coffers of healthcare, and yet we are penalizing those who are too busy caring for patients to do so.  I honestly get depressed when I see all of the waste around me and yet face huge cuts to my reimbursement.  It shows people don’t understand.  It shows people don’t care.  Do you want doctors who care?  Then put your money where your mouth is.  Stop rewarding the parasites.  Stop throwing money at the turnstiles.  Stop rewarding the spenders.

There are some of us who still care, but it’s getting harder to stay that way.

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13 replies »

  1. The “facility fee” for outpatient visits is the biggest scam going in medicine currently. Anyone have any idea why Medicare and other insurers put up with it?

  2. Dr Rob- Very well done, sir. You speak of true patient centered care the way a chiropractor would.

  3. Connie: I am sorry you are bitter about EMR’s. I am sorry I have had a great experience with them. What does that have to do with the content of this post?
    Gary: You are right. It’s not usually my style to bash stye over substance. Sorry.

  4. Rob,
    I guess English was your major. So be it. After all you may pride yourselves on your degrees but common sense is a perspective based on the user from all walks of life. If you agree or disagree ,it has little bearing regarding grammer.
    This blog is an exchange of ideas that works best through persuasion and understanding.So it does mean that information and their meanings are sometimes misunderstood.
    Health Care as we all know is about cash and savings is not in its creed!

  5. Rob,
    Everything will be hunky dory with EMRs in every office and hospital. Do not fret.

  6. Barry: Hospitals cannot bonus based on utilization – it breaks the Stark laws – but their idea of a “productive” physician is opposite what the system wants. Hospials desire increased utilization of services (which equals increased revenue), while the system wants a decrease in utilization (which equals decreased cost). This is made worse with physicians whoe benefit from increased utilization – namely, procedural specialists. Primary care doctors are caught in a contradictory world where thier goal should be to keep patients healthy and to keep their cost down, but their employer’s goal is actually the opposite. It should be noted that some hospitals tack on a “facility fee” for all visits, including primary care. This happens when docs have practices on the hospital premisis.
    Gary: FIrst a gentle suggestion: get an editor to check grammar. That aside (because poor grammar doesn’t negate what is being said), the point of the post was that the system rewards spending over caring. I am not saying that docs should be exempt from cost scrutiny; I am saying that the system unfairly cuts the very docs who could save money. It pays far more to not care and instead gouge. The system has dictated who survives, and the ones who survive best are the ones who need to get the axe.
    Paolo: That’s easy to say from the outside. What I see is a huge political football that will be made worse by the more divided nature of the coming congress. Do I think politicians will be willing to crucify doctors to make a political point? Do I have to ask that question? Of course they would be willing. It would be really stupid, and I hope they don’t do it, but my faith in congress is tenuous at best.

  7. If hospitals can reward their staff doctors with bonus compensation based on how much business they drive into and through their hospital(s) or how many well compensated procedures they perform, then payers, including Medicare and Medicaid, should be able to identify and publicize who the high utilizers of healthcare resources are, at least on a risk adjusted basis.
    We should then be able to develop incentives for patients to choose the more cost-effective doctors and hospitals and to reward those same providers with a combination of bonus compensation and, hopefully, more patients. Risk adjusted capitation for primary care is OK as far as it goes but the real money is spent on specialists, especially for work performed within a hospital inpatient or outpatient setting or at a stand alone hospital owned facility such as an imaging center. Hospital facility fees are also a significant contributor to rapidly rising healthcare costs. Tiered in network insurance products would also be helpful in developing some countervailing power against the hospitals and large physician groups owned by hospitals as would disclosure of insurance contract reimbursement rates by CPT-4 or ICD-9 / 10 code number or per episode in cases where bundled pricing is used.

  8. I understand the Medicare payment Problem that has everyone on their heals. As a advocate of Health Care reforms.I feel that patients are being placed in Harms way and without any say. I know that medicare reductions are cripping primary doctors in delivery of Care.
    The Facts are that Doctors are a big part of the equation in solving these problems that CMS ,Government and Health Insurers have propugated and abused.
    Honestly, if it were not for individuals concerning themselves with only their bottom line.Answers could be readly available.
    Like Government,this industry has become self perpetual and I must say so; Fat and lazy as well. Health Industry has lost sight of its purpose and has allowed Insurers to Dictate Pricing,Procedures and Billing. Enslaving themselves to the whims of insurance Companies.
    You Folks want to find the root of the problem. Look at the monuments of Health Care,excessive pricing and Lavashed Profitability. Look closely to the arrogance and the unnessary utilization and exploitation of the patient. The sum of the symptom analysis is to prolong problems and divest them into higher profitability ratios! Absolute power corrupts absolutely!
    Changing the direction of the Health Care is tearing down the walls of Health Insurers!Providers bet against their Patients when they sign contractual agreements that Prevent individual Negotation and squash free Market Models!
    If You cannot rule on transparency ,Fairness and the almighty free Market Model . Than you don’t deserve to continue this counter productive rein on Health Care.

  9. Dr Lamberts:
    this is what happens when you are trained to be the type of provider that takes and practices by the Hippocratic Oath; we make a committment to help others, and those who are threatened, inconvenienced, or just plain disrupted by our efforts and intents will stop at nothing to impair the process and profession.
    THis health care deform legislation has reinforced what many of my respected and responsible mentors taught me: every one is a damn doctor until the proverbial crap hits the fan, and then these charlatans are the first out the door and leave the doctor and patient to be crapped on! So, if you are an advocate and care about the practice of medicine, get off your ass and start championing for a return to what is the basis of health care that we provide.
    Or, your silence and lack of effort will gain you what it is worth: being a servant, being an outcast, and eventually, being useless!
    Silence is death. That adage has merit!
    Just read the dissenters who don’t want this heard and considered!!!

  10. Given that the SGR has always been ignored for the last 13 years, there is close to zero chance that it will ever be enforced. It’s like the AMT exemption that gets fixed every year at the last minute, but nobody wants to permanently fix it because it costs too much on paper.

  11. Great post… I find it interesting that in American history (i.e. the great depression), ingenuity is at its finest when the economy suffers. Could it be that our society is so desperately trying to tread the economical waters right now that it is sinking to new depths to stay afloat? At the same time, ethical standards are being rationalized in order to “survive.” How are we going to reverse this trend when people who are looking to make big cash outnumber the people who entered our field to care for others?

  12. Well said, even with your hat on. Health Care is the new piggy bank for the US Government and the trough for the parasites. Much will be paid for out of this bank, but the patient care you provide will not be covered.

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