We are a commune of inquiring, skeptical, politically centrist, capitalist, anglophile, traditionalist New England Yankee humans, humanoids, and animals with many interests beyond and above politics. Each of us has had a high-school education (or GED), but all had ADD so didn't pay attention very well, especially the dogs. Each one of us does "try my best to be just like I am," and none of us enjoys working for others, including for Maggie, from whom we receive neither a nickel nor a dime. Freedom from nags, cranks, government, do-gooders, control-freaks and idiots is all that we ask for.
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Friday, June 14. 2013
I think everybody's ideal is to have an internist or family practice doc who knows you well personally as well as medically, and where you can call or come in anytime if you have a concern. For various reasons this has become elusive.
Based on what I have seen, three trends are growing. The first is the Doc-in-a-Box or, more likely, a PA in a pharmacy.
The second is concierge medicine in which, for a modest annual fee, you have unlimited contact - 24/7 - with your generalist.
The third is generalist docs who will not accept insurance but who charge modest fees and will offer a bill that you can send for your own reimbursement, if any. They can charge modest fees because they do not need to hire a large back office staff for coding and billing.
It's a good idea to have a generalist who knows you and your family. With ObamaCare, I think all three of these modes will grow in popularity, especially the last one. They are all working mostly outside the system. They are not likely to want to make time to see you, however, unless they have met you (except for the PA in a box trend).
Generalist physicians, whether Family Practice, Internal Medicine, or whatever, are the ultimate docs. They see everything, major and minor, and know when to refer. People who want to use their Medicare and Medicaid are going to have a tough time with office visits in the future.
I had always aspired to be a country doc, a generalist, in the New Hampshire countryside, but became too fascinated with what I now do. I had dreams of fixing broken arms, stitching up nasty cuts, treating poison ivy, delivering babies, consoling the terminal, sending appendicitis patients to a surgeon friend, etc. It's kind of funny, but my generalist friends tell me that half of their work is Psychiatry anyway.
With the training I had, I suspect that I could still do those country doc things pretty well, but my malpractice insurance does not cover it. In my training, I caught 42 babies. Some were dangerous and complicated. As I have admitted here in the past, I refused to participate in abortions not because I am so religious but because I did not want it in my memory.
Primum non nocere.
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Or a nurse practitioner-in-a-box.
FYI, Medicaid/Title 19 patients are already having a tough time right now, at least in CT: a year to get certain referrals, local hospitals won't do biopsies anymore ( The ones we can't do in the office) and have to travel 40-50 minutes now ( many without reliable transportation).
Wait until next year when the stuff really starts to hit the fan.
It was my thinking quite a few months' back that this might be the result of Obamacare = doctors refusing to participate. And since most doctors are not interested in being federal employees, they will find a way around Obamacare and maybe even a way to undermine it altogether.
If Obama's plan was to destroy the health insurance system in this country in order to replace it with a federally-run healthcare system, I don't think it is going to work out as planned. We Americans are pretty obstinate and like our freedoms.
I think we will see more and more of these doctors exit from the Medicare / insurance model and start being cash only. And, as I have seen lately, these are not expensive, for-the-rich only deals. These are truly affordable monthly plans for a physician's care and basic tests that I think even a person with a minimum wage job could afford.
Then, all people would be interested in buying would be high deductible plans for emergency use. Voila! Healthcare system reboot. And rebooted in a way that takes advantage of the free market, gets the government out of the way, and makes things cheaper. LOL.
Could happen --and the big problems of jackpot juries and fantastical insurance against it, not to mention portabilty, would all be 'touchable' as they should have been all along, but for the insane third party distortion.
As these models grow, and increasing number of physicians move outside the system, do not be surprised if The Empire Strikes Back. As access to physicians shrink dramatically due to the regulatory crush and dropping reimbursements (as has already happened for Medicaid patients in most states, and Medicare is not far behind), states will respond by making the accepting of Medicare/Medicaid/Obamacare patients a requirement for licensing. Some states have already gone this route (Massachusetts for one, if I recall), and this will likely kill the nascent concierge/cash practice movement in its cradle.
In three year's time? That's about all Obama has left. That sounds like a pretty big fundamental change that would take time to do.
The dismantling of the industry by doctors refusing to participate won't be overnight either. To make an impact on the Obamacare system it would have to be the majority of physicians taking on the cash-only model.
For now, there are probably enough docs who will continue as they are.
BTW, seniors would also benefit greatly from this model. Wouldn't that be interesting to change how Medicare works as well? How about the $100/mo. from Medicare paid directly to docs for the 'senior subscription service' for the basics. I would think that would be a LOT cheaper than what's going on now.
My husband and I are relatively health elderly. We have a backup insurance plan provided by my husband's former employer. As a condition of this plan, we must take Medicare Part B. We are kind of hoping that the employer dumps us onto the exchanges, in which case we will drop part B and get a concierge relationship going. I'm not sure what happens with the catastrophic plans in January, but one of those, combined with a concierge practice, would work, if it's possible.
It is already very difficult to find a gp who will take Medicare - we are pretty much using the urgent care places if we need it. It's not great and because the turnover is high, you never establish any kind of relationship with a gp.
We do the third choice in our family, with a $10,000 deductible. It is worth it.
However, our plan will become illegal in January.
I see the addition of a Norman Rockwell print. It wasn't there when I 1st read your post earlier 2day. I have the same print (purchased in Stockbridge, Mass. many years ago). Did BD add it or yourself? (a rhetorical question I believe).
Tho a Canuck my heart lives in New England. Recently made my umpteenth trip to Stockbridge and it never gets old. Maybe I'll "expire" there.....
Love Tanglewood and the "Yankee Candle" factory in Lennox and it's surrounds. Actually have Officer "Obie's" autograph from May 8, 1989...'cost' me a Budwiser.
I bought catastrophic and went to pay-as-we-go 20 years ago. The savings have been grease-drippingly phat. None of us suffered anything worse than the kids growing up with the mental habit of automatically reserving a trip to the doctor for things that actually called for a doctor. And no we didn't set each other's bones or pull our own teeth, either. Look, it just stood to reason, that a transaction is between two parties. If you bought a pair of shoes or loaf of bread with a three party transaction, someone has to feed that third party and see to his living. That'd be wasteful enough on its own, but then add in that you don't get to speak to the shoe salesman nor him to you, but both to and fro the stand-in, then you have the great opportunity cost of the missing communication --the communication that is factor two in price-setting, just after supply & demand.
Really, to wreck a market, just mandate a third party to every transaction.