family practice issues and general life events

Posts tagged ‘primary care’

Obamacare Faults

Yesterday, I made half the country mad because I actually agreed with an aspect of ObamaCare or the Affordable Care Act.  Today, I am going to try to make the other half mad, and discuss what I view as its biggest faults.  Since it is 2,200+ pages, and I have read them all (didn’t say I understood all of the legalese but I did go through it) first of all it is too big and has a lot of crap that has nothing to do with healthcare in it.  Why the hell is there anything to do with the student loan industry in a healthcare bill?  Now I understand we are dealing with Washington and this is politics as usual, but it highlights what is wrong with Washington and politics as usual.

First of all, it adds for the increase in 16,000 IRS agents.  Now when I think of compassion, I think of the IRS.  Wait no, no I don’t.  !6,000 new IRS agents, and 0 doctors.  No monies for training programs, nothing to address that while the rural areas are already short physicians for those currently with coverage and you have potentially increased the amount who have coverage, it fails to address this need.

No it adds 16,000 IRS agents to make sure you are either paying your insurance premiums, your company is, or the fine.  Now I don’t know about you, but having the IRS messing around in healthcare, not exactly my cup of tea.  And the Supreme Court just ruled it was a tax.  A tax for choosing to do nothing.  Which also makes me leery, will they now be able to tax me because I don’t like cauliflower and refuse to eat it?  Maybe with cheese, but I think slathering cauliflower in fake processed cheese ( I do like Cheez Whiz) takes away most of the health benefit.  If my BMI gets over a certain amount, am I now going to be taxed?  This allowing for taxes to be done for not purchasing a product is very disturbing to me.

Additionally, the penalty, $500 a year for an individual, $1500 for a company over 50, was this drafted by someone who has never actually purchased insurance.  You just told the companies, if you don’t cover your employees, well your fine is less than what you would have paid for coverage.  And those companies are more likely to drop coverage.  They are currently already playing games with their policies hoping to come in with crappy plans that can be grandfathered in before the deadline, though I am not certain that the deadline hasn’t already passed.  So in one sense the plan has decreased coverage for many who were previously covered.

And as to the biggest fault, which I alluded to before, it does not address the biggest problem facing healthcare- the doctors.  And while there is a shortage of specialists, those residency slots are filled, it is the primary care slots that while still open, even if you were to fill them completely full (which they are currently increasing medical schools and class sizes) it is estimated that the open slots would not be able to cover the amount of physicians that will be needed.  I focus on the physician and not the midlevels, who while they will be helping to cover this role, CMS has the data showing that primary care physicians coordinating the care tend to lead to better outcomes.  While they can refer as necessary they are better equipped to handle many of the more complicated medical care in their office than a midlevel.  These reports can be found on the CMS website going back as far as 2006.

In fact, in the ACA funding for the program cuts money from Medicare.  That being said, as the largest voting block is starting to become eligible for Social Security and Medicare, I doubt that these cuts will ever take effect, without a major overhaul of the system that ends up either privatizing or transforming into something completely different.  I doubt that the drafters of ACA actually spoke to any of the physicians that are currently in practice.  Sure they spoke to the AOA and the AMA and their lobbyiests, but the problem with leadership in these groups is that to get to those points they have often either been in an academic practice for years, or no longer practice daily. This leads to gaps between what those practicing see as a need, and what those representing us view as a need.

And for those practicing in academia, well let’s just say outside of those in residencies they can often cherry pick their patients, and therefore compliance is very good.  Had they spoke to those in practice, one thing that needed to be addressed was the flawed SGR formula in the Balanced Budget Act of 1997.  This is how Clinton and Congress were able to express that Medicare would be sustainable and there in the future.  What is the SGR?  It is the sustainable growth rate which was put in place in an attempt to control the growth of the medicare fees by limiting what it pays for physician services.  It is calculated based on what expected expenditures were in comparison to actual expenditures and adjust rates accordingly.  Since its inception, it has also supposed to have gone down.  In fact, had there not been a yearly fixed, physicians would have seen a cut in pay of 37% since its enactment.  And this is why ever December or every other (depending on whether Congress deems it necessary for a year of not having to worry) physician groups yell out about dropping their Medicare patients. And those that don’t have Medicare join in the fight because insurance contracts base their rates on Medicare, so anyone who is not concierge, well they all have a reason to worry.  Anyway, Congress despite being asked repeatedly choose to kick the can down the road.

Current payment models, actual encourage procedures rather than physician visits.  As primary care, most of my money actually comes for the visits, and the more complex, they more I get paid, up to a point.  I don’t however, have unlimited time with a patient as I would like.  However, I live in an area where access to specialists are limited, not as bad as many areas, but wait time for a neurologist often borders on 6 months, so I have to take care of all, at least until I can get an opinion.  The ACA does not help this.  It does not help with the increased wait time to get an appointment for a physician.  My wait time for new patients was sitting at a month.  I was able to decrease that slightly by not taking lunches and in the fall, I am going to add evening hours.  It is all that I can do, but I still need to be a parent to my kids.  Hopefully, in a year, I will have room to hire another physician to help with this issue, but the problem is finding someone who wants to go to a rural area and practice primary care.  For all that it claims to increase access to physicians, it has done nothing to increase the number of physicians to see them, and it may result in an increase of ER utilization until that problem is addressed.

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When did my career become a secret?

A couple of days ago I noticed something. When people ask me where I work, I don’t usually introduce myself as a doctor.  It was one thing, when buying a car, that I would off-handedly say, “I work at the hospital.”  You are always told adding Dr to your name adds zeros to every purchase, buying a car, building a clinic, buying a house.  Anyway, in purchasing, you just don’t do it.

However, this time it was different.  I was eating dinner with my children at the Olive Garden, when the waiter asked what I did for a living.

I was wearing scrubs, so the question was initially, “So did you work all day.”

“Yes.”

“So what do you do?”

It was not the waiters fault, he was perfectly hospitable, taking care that our table had drinks and attention that anyone would appreciate.  We talked about the iPad 2, since I happened to have both children’s and mine with me.  And if I thought it would be a good deal to buy one, and if we liked ours.  All perfectly pleasant.  It was only when he came over during a discussion with my oldest, as to why I could not donate blood at his school’s blood drive the next day.  (Previous years, I have, but this year it was on a Wednesday, and most Wednesdays I barely have time for lunch much less time to drive 30 minutes to his school, donate blood, and return to work)  So I pulled up my schedule on the iPad, and showed him how full it was.  Still not overly impressed, he said, what about after work?  At that point, I promised him, if by some miracle of miracles, I were to finish by 4 pm, I would donate blood.  However, since I have yet to get out of the office by 530pm on a Wednesday in about 8 months, well it probably was not going to happen.  And this is when the above conversation happened.

I don’t know why I stuttered.  I am not really ashamed of what I do.  Obviously I would not be blogging about it online if I were.  But stutter I did, as I admitted that I was a physician.  Admitted, is this what the once noble profession I dreamed of being as a child came too?  Or maybe it was that I was caught off guard, since it was an early dinner due to having to leave work early in the afternoon to take my youngest to speech, and then kill time between therapy and a skate party.  And maybe that I was worried I would have to explain.

I spend a lot of my day explaining things.  Why I don’t take call, why I don’t go to the hospital regularly, why I have no desire to work in the ER, why I leave early on Tuesday and don’t see patients on Thursday.  And maybe that was the reason.  However, he did not ask for explanations, he actually was reassuring that my career was not equivalent to that of a drug dealer, even though some days, I think that is what I have become, at least in the eyes of some patients.

Maybe I spend too much time online, reading the terrible things people say about doctors, how they make too much money, they rush in and out of rooms too fast, they take too much time to get to their room, that they just don’t care.

I heard a joke once in training that the person who yells out first “Is there a doctor here?” is probably a physician themselves.  And sometimes, I wonder if that is true.  The days, weeks, months, years of fighting public perception as a money hungry individual willing to throw their patient under the bus for a dollar on one side, and the fighting for the dollars rightfully earned trying to provide the patient care that they deserve may have worn us down.  The time spent fighting against liability claims and fear of lawsuits despite no wrong doing, maybe those have worn us down as a profession.  The stories of physicians who have stopped to help someone on the side of the road and despite no wrong doing receiving a lawsuit for a bad outcome.  Maybe that is why we no longer stand up and say I am a doctor.  Or maybe, I just I don’t want to be chased through the grocery store to look at a mole.

And in my case, where my husband and I made the choice where he would take my call, so that one of us could be at home at night with our children, maybe I just didn’t want to explain one more time, why I don’t go to the hospital.  It is not that I can’t, it was that I put my kids before my career.  It is the years spent justifying why I don’t do shifts in the ER like my husband.  It is the time spent alone, at night, wondering if I made the right choice.  Did I do what was best for my patient?  Did I make a difference for the better?  Or what am I missing on that patient?

For the most part, I love my job.  I like that I am in most of my patients’ lives.  In many instances, after they get a recommendation from a specialist, they come back and ask me what I think they should do.  Or if they could have a second opinion, not necessarily that they disagree with the first, but that it is a major decision and they would like to have another perspective.  I don’t make as much in my clinic, as my husband makes doing his shifts in the ER.  I see the reports as to doctors not choosing primary care residencies, and I understand.  The money is not as good, and most of us graduate with a large amount of debt.  And you have to spend a large amount of time fighting, fighting insurance companies, fighting for payments, and watching the general population equate your training with that of a midlevel.  Even though you have twice as much training, 4 times as much debt, and way more liability.  And then at the end of the day, you notice the pile of paperwork- not visit notes, but other paperwork.  Prior authorizations, home health messages, home health certifications/re-certifications, various forms for patients regarding why they cannot work, disability questionnaires, and random notes that the patient wanted you to write for them yesterday.  Add to that orders that the specialist decides that they want done, but don’t want to obtain the prior authorization themselves, despite having the pertinent data needed to get the test approved, and yet they don’t send it to you.  So I understand why students are not choosing a career in primary care.

And maybe it is just a combination of all of those reasons that I don’t introduce myself as doctor out in public.  At maybe, just maybe that is why I stutter when asked what I do for a living.

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