Doctoring in the trenches, using our knowledge and techno-gadgetry to enhance or save lives, is uplifting. Reading news on heath care reform is “not so much.”
Reform has yet to begin, but businesses and doctors are already changing their behavior. As chronicled in this depressing piece, it is clear that doctors are joining consolidated practices and choosing to be salaried more often.
“Last month, a hospital I’m affiliated with outside of Manhattan sent a note to its physicians announcing a new subsidiary it’s forming to buy up local medical practices. Nearby physicians are lining up to sell—and not just primary-care doctors, but highly paid specialists like orthopedic surgeons and neurologists. Similar developments are unfolding nationwide.”
Common sense would argue that a salaried doctor without any productivity incentive will see fewer patients. It is human nature. No, most doctors will not just clock out when someone is really sick, but the pressure to add elective patients on a busy procedure schedule, or full office day diminishes greatly when there is no skin in the game.
And, the demand/supply equation is growing increasingly askew. Demand for healthcare is on the rise. Thanks to our skill and technology, patients live longer. With increased longevity comes more chronic diseases. As medical technology advances forward, so does the accepted standard of care.
As demand rises, the supply of care is decreasing. Due to falling reimbursement, more doctors are opting out of medicare. Salaried doctors will see fewer patients. More middle-aged doctors are either retiring early or choosing non-clinical careers. Talented young people are choosing medicine as a career less often–but even when they do choose to doctor, they are less likely to choose primary care. Ask veterans how easy it is to see a specialist?
The loser in the above equation is the consumer of health-care–you and me.
Think this isn’t real, just a blogger droning on.
Consider Mr M:
Call Mr M (your patient), “he had a small stroke and wants to know whether he should take warfarin to prevent another one,” comes the text message.
So I call, and Mr M, an 85 year old who is incredibly functional tells me his story.
“Which hospital were you at,” I ask.
“I didn’t go the hospital, it was the weekend, I didn’t want to bother the doctors, and it was only numbness on my left side… “I am a lttle better now,” he adds with an optimistic tone.
His MRI, ordered by his primary care doctor showed an isolated small stroke. The decision comes down to the choice of two disparate blood thinners. After explaining the dilemma, I add, “we really need you to see a neurologist.”
“That’s what my primary care doctor said as well, but I called two neurologists, and the soonest they would see me was two months.”
Both neurologists he called are employed by a hospital. Is this just a coincidence?
I’m engaged now, so Mr M’s decision will get made something like this: in between ablations tomorrow, I will mosey down to the radiology cocoon and find one of the incredibly talented neuro-radiologists my hospital is fortunate to have, and go over the MRI. Then, I will call the neurologist and tell him the story and MRI findings. With these two opinions, I will make a decision on blood thinner and call the patient with the answer. He will no longer need the neurologist opinion.
It will be fun finding out the answer. It will help the patient. I will be reimbursed zero for an hour or so of my time. This fact is ok with me, in my present state, but not so with many doctors, and is it really fair?
This scenario is the tip of the iceberg.