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, May 16. 2014
"Nine out of ten doctors would not recommend anyone go into medicine today," the headline of an online news post read.
An article in Forbes Magazine last month cited the selfless dedication physicians bring to the practice of medicine caring only for the well being of their patients. Both statements are gross exaggerations. While many doctors are unhappy with the changes in medical practice they are not retiring in droves, and while most doctors care a great deal for their patients there are also those who care more about their compensation. Certainly more of the older generation of practitioners, my generation of physicians, have been stunned by the changes that have occurred over the past 25 years in the delivery of health care, but also by the loss of a sense of power doctors once had. The axis of physician, nurse, patient is now a mosaic which includes many other "providers" not anticipated twenty years ago.
One of the first changes was to remove the doctor from his pinnacle by calling him (his/him will stand for both genders in the interest of brevity) a "health care provider." Thus, medical care deliverers became like Dr. Pepper drinkers, "I'm a Pepper, she's a Pepper, wouldn't you like to be a Pepper too?" We groused about it but only a few of us saw the dark clouds on the western horizon, managed care was approaching. Up until that time the community hospital was basically a doctor's club complete with private dining room. As care became more complicated and sophisticated - intensive care units and CAT scans did not exist in the 1960s when I was an intern and resident - the hospital became more of an independent institution that could serve patients with its own staff to service physician referrals.
In time, the hospital and the physicians on staff found themselves
The best summary and description of what has happened to the practice
If you have a primary care physician, he may come to say hello and
even offer recommendations to the hospital docs, but he doesn't have to.
Thus, the touching portraits of the family doctor at the bedside in the
home of a sick patient will be something to be seen at the Norman
Rockwell museum in Stockbridge, Massachusetts and the old model of the
doctor patient relationship may belong in the museum too. Perhaps that
is where we are headed in general. My adult children read the news on
their cell phones, text their friends rather than call them, and are
content with a different quality of doctor patient relationship. They
look to the web as much as to me for information and neither has a
single primary care doc he turns to for advice. With all of that said, I
have always enjoyed being a doctor and if I were just to be starting
out now I would be participating in the system as it has evolved not
lamenting the loss of what was, and humoring the old fogeys who want to
talk about how it was way back when.
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Doctors love to blame insurance companies yet fall into two categories on what to do: 1) Government Health Insurance (obviously some utopian plan not like Medicare or VA) 2) Fully self pay. I've worked in plenty of big companies as well as my own firm as a consulting engineer and hear the same complaints from my corporate colleagues. Doctors lost their freedom and professional status by not fighting for them. If you want to stay in control of the diagnosis and treatment process then you will have to take on some of the management role as well. If you let it be outsourced you get what you are complaining about. Stop thinking the MD title entitles you to this, the PA's, Nurse Practitioners, etc will grab it for only a few bucks less. But they have more clout in the legislatures. Get ready to sell the concept that your skills are worth it and cheap in the end.
Try getting doctors to come together, it is like herding cats. You can't make an orchestra out of soloists. Some docs have formed LLCs and buy practices to control a geographic area, and some have become hospital administrators.
I am with you, old-timer, but not as sanguine about the future of our priesthood.
Well, esteemed colleague, would you rather I be sangue froid?
Doctors tried to fight for their freedom and professional status back in the 60s when they opposed Medicare. Unfortunately, there were more non-doctors (voters) who wanted the "freebies" promised by the nanny state than there were doctors (voters). As with all forms of socialism - and make no mistake, Medicare is a socialist form of medicine - when Smith is paying for the goods and services that Jones is receiving, certain predictable things will happen.....and they did.
DirtyJobsGuy seems to understand the concept that those who have more clout with the pols will get what they think they want. That in a nutshell is the problem - we have gone from a republic where individual rights were ensured to a democracy where the mob rules.
Now, to be fair, once medicare was in place, too many doctors fell for the trap and accepted the money in exchange for their freedom - ultimately, they lost both. I see to many doctors who still don't understand this, They complain that Medicare (the government) should pay them more for their services.
Government intervention with the market is why we ended up with high prices (what individuals pay for individual services) and high costs (the total amount the nation spends on medical services).
When providers (doctors) accept payments from the federal govt that are not regulated by market forces, but instead are "determined" by some experts in Washington and they enjoy decades of prices that are higher than they would be in a free market, they must recognize that the pendulum will eventually swing and accept decades of artificially reduced prices.
Similarly, patients who for decades have demanded more services because they perceive that somebody else is paying for it, must now recognize that when Uncle Sugar is paying the bill, he will eventually insist that he has the right to limit access and quality.
I have an old- style Doc, and I am not a number to him. I intend to keep things that way for myself and for my family. DMV-type medical care is not for us.
When I was a kid, the pediatrician did house calls before and after office hours with his big black bag. He was like a member of the family, and he and his wife always stopped by on Christmas Eve after church for a drink and a carol around the tree. I always wondered how many drinks they had while making their rounds.
Good folks for sure, and they knew the families well. We all went to the same church in the same small MA town. A good life.
My doctors three person practice split up recently.
One doctor joined a concierge practice, with a business model based on a retainer plus a price list. His back office work is done by the concierge service, and other local members of the service provide his vacation back up.
A second doctor stayed independent, but dropped all insurance. He charges list price, won't negotiate, gives you a coded write-up when you're finished with the appointment and lets you deal with third party reimbursement.
The last doctor joined a corporate practice. He's an employee, works regular hours, and has nothing to do with any of the back office decisions. He doesn't have to think about real estate, hiring nurses, patient information systems, coding, reimbursements or anything except medicine.
My observation, and I really don't know facts here because its only three people (small sample size problem) and because hardly anyone is dispassionate about how medical care provision is changing (so there are agendas), is that the concierge guy is happiest with his present choice but very uncertain about the future stability of the concierge company he joined. The doctor who remained independent is moderately, even reasonably happy, but his patients are angry with having to deal with all the insurance crap (the doctor responds "welcome to my world") and he's losing patients. His future is up in the air and hes a little fatalistic about it. The doctor who joined the corporate practice is unhappy with her compensation, but reasonably sure of her future and happy not to deal with anything except patients.
Since I've dealt with all three of the people for my own care over the years I'm not sure what to do, but, for now, I've stayed with the independent doctor.
I think there's more to the story.....
The doctor who is now employed by the corporate practice has more to deal with than her patients. She is employed by the corporation, not the patients. Therefore, her primary concern is to make her corporate masters happy, not the patients.
I'll admit there's a fine line - if the patients are unhappy and voice this to the corporation, she's in trouble. However, keeping a patient happy has less to do with providing the best treatments and advice than with bedside manner, i.e. perception trumps reality. If the corporation says "Treatment A may be a little better than Treatment B, but it costs too much", the doctor has a very real incentive to give your treatment B. NOTE - THIS HAPPENS ALL THE TIME RIGHT NOW.
Who would you rather trust to decide what treatment you get, the doctor who deals with you face to face or the corporate owner who doesn't have to face you and your family when the cheap treatment fails?
If it was up to me, I would do what you did (assuming all three docs are equally competent) and pick doc #2. The money you pay him is for medical care, not for medical care plus insurance billing. His incentives are aligned with yours - if he doesn't provide care that you (and you alone) are happy with, you'll seek care elsewhere.
Now, in the interest of FULL disclosure, the way that Medicare and insurance companies set or negotiate fee schedules makes it financially advantageous for some doctors (notable specialists) to become hospital employees and have their office operate as a hospital outpatient department. Instead of having the insurance company tell them what the fee schedule will be (no negotiation), the insurance company agrees to pay the hospital X percent of its usual fee (and then the hospital sets its "usual" fee such that X% of that fee is what it wanted in the first place). Right now, there is a great deal of variability in how much pressure the hospital (corporate or public) puts on doctors to lower costs by using treatment or brand A versus B, but as independent doctors offices get phased out and finances get squeezed, the hospital administrators will have the upper hand and the doctor will have more incentive to obey their non-doctor masters.
I think the best any of us can do is to stay with the doctor you trust and who has your best interest at heart. Even the "Corporate" docs, ones who sold their practice to a consortium, still try to do their best, at least in my community.
I guess if you view the crappy future of medicine as inevitable, you can work yourself up to this attitude and convince yourself that the real problem is getting people to "face reality." Myself, I don't plan on swallowing it passively, and I'm unsure why other voters and/or patients should, either. As long as people are willing to buy their own medical care the way they buy their own food, clothing, and shelter, they'll be in a position to demand something better. If they think of healthcare as something the government "gives" them, they won't.
Managed care began with Kaiser Permanente in California. United Health Care, Blue Cross Blue Shield and others are not government agencies, they are part of the insurance free market.
I wouldn't call the marketplace for private insurance "free". It is clearly socialized. While many incorrectly state that socialism is a system where the government (the masses) OWN the means of production, that is not fully correct. When the government CONTROLS the means of production, they have de facto ownership.
Looks like we're moving towards the Soviet model for medicine in that doctors are just cogs in the machine.
That will teach you to be largely Republican!
what Texan99 said; care is expensive because we delegated paying for to 3rd parties and now those 3rd parties are tightening the screw in the way they see fit. Docs getting out from under all that as described is a healthy development. We'll have the possibility of better lives for docs and patients just in so far as we can return the payment function to the patient. There are ways in which that might happen if the republicans can win an election or two.
In MT, we used to have a "county nurse". She would drive around to all the ranches and make sure every wound was cleaned, stitched up properly, etc. Folks got their tetanus and rabies shots and polio sugar cubes. She kept a close eye on babies and got folks in difficult medical situations into the town doctor. Sometime she drove them, but mostly she just leaned on the relatives to get the needy patient into town. Of course, in the winter when roads were frequently not available she would manage in other ways to keep her community healthy. The county nurse is gone now, eliminated in favor of bigger hospitals with bigger science machines, etc. She has been gone for years. Now we have hundred families driving into town for everything--great improvement that "new science" put into effect. Then folks ask "whatever happened to our sense of community?" Well . . .