Monday, May 11, 2009

The Physicians’ Perspective: Medical Practice in 2008

"Through responses provided by approximately 12,000 physicians nationwide that included more than 800,000 data points – as well as through written comments by more than 4,000 physicians – the survey offers a unique and valuable insight into the practices and mindsets of today’s doctors."

Some key findings:

Only 6% described the professional morale of their colleagues as “positive”
78% said medicine is either “no longer rewarding” or “less rewarding”
60% said they would not recommend medicine as a career to young people


Only 17% rated the financial position of their practices as “healthy and profitable”
82% said their practices would be “unsustainable” if proposed cuts to Medicare reimbursement are made
65% said Medicaid reimbursement is less than their cost of providing care
36% said Medicare reimbursement is less than their cost of providing care
33% have closed their practices to Medicaid patients
12% have closed their practices to Medicare patients


49% of physicians indicated they will take one or more steps in the next one to three years that will reduce or eliminate patient access to their practices:
11% said they plan to retire
13% said they will pursue a job in a non-patient care setting
20% said they will cut back on patients seen
10% said they will work part time
7.5% said they will work locum tenens
7% said they will switch to concierge practices


So folks, for those of you who're steaming forward trying to establish a Medicare-type plan for everyone in the country - where do you expect to find doctors who will be willing to accept them? More and more doctors are finding that public health "insurance" programs reimburse them less than they're laying out, thereby making such practices frankly unsustainable. In response, more and more practices are simply not accepting such insurance programs.

Consider: these programs which are designed to help the poor gain access to care are actually making it more difficult.

How can the state respond?

Oh, we get fun stories like this from Illinois where the attorney general sued clinics who were simply trying to stay in business. They refused to accept more Medicaid patients because they just could not afford to continue operating at the reimbursement rates they were receiving. Yes, apparently the state thinks it has the right not only to dictate prices but also the right to force doctors to accept them. Isn't it nice to see doctors becoming government serfs? Does anyone think actions like these will encourage people to enter the healthcare arena, much less primary care?


My solutions: return free market medicine to primary care. Don't pretend that government reimbursement is full compensation for the doctor's time and effort. Care given to those who cannot pay should be understood as charity care and should be able to be deducted come tax day.

14 comments:

E-man said...

I wish you were president.

Anonymous said...

A couple of quick observations:

1. Physicians are not alone. People in many professions get disillusioned at some point, think of leaving, wish they had chosen a different line and would not recommend the profession to a child. Look at teachers and lawyers to name a few.

2. One of the problems found in the survey is time spent on paperwork. A one-payor system or universal health care might change that.

3. The complaints about not making enought/not being profitable are hard to evaluate without knowing what these physicians clear and what their overhead per patient is. The public is not going to be sympathetic without that transparency.
Salary and earings reports consistently place all types of MD's in the top 5% nationwide. (This is not the case in many other countries where drs. make decent, but not top 5% earnings). Granted, this in not what the wall street types make, but drs. have a lot more job security.

I wonder if the real problem/dissatisfaction is the inequity between primary care and specialists. The premium paid for specialists as compared to primary care physicians is hard to justify and is one of the big problems in the U.S. system.

4. If drs. could deduct what you call "charity care" would enough drs do it? Not enough drs are willing to treat medicaid patients now, so what makes you think more will if its purely free care?

Orthoprax said...

Anon,

"Physicians are not alone. People in many professions get disillusioned at some point..."

There has been a historic decline in career satisfaction and morale among doctors in recent history. That other careers also have problems doesn't change or diminish this. But for the amount of sacrifice people put into becoming doctors (far greater than in becoming a lawyer or teacher) and the level of responsibility of the work, it's foolhardy to think people of high caliber will continue to sacrifice for a delayed satisfaction that never comes.

"2. One of the problems found in the survey is time spent on paperwork. A one-payor system or universal health care might change that."

Could be. Could make it worse. Though if doctors as a group refused to accept insurance at all that would reduce paperwork by orders of magnitude. In many cases private HMOs and other insurance companies can be just as bad as the government.

"3. The complaints about not making enought/not being profitable are hard to evaluate without knowing what these physicians clear and what their overhead per patient is. The public is not going to be sympathetic without that transparency."

Funny thing about refusing to accept insurance is that it doesn't rely on public sympathy. You just do it. I don't see why it's the public's right to judge whether their doctor is making an acceptable living. They just shouldn't be surprised to find that more and more doctors are going to drop out of the system.

Some doctors are less willing to immolate themselves to the industry than others.

"Salary and earings reports consistently place all types of MD's in the top 5% nationwide."

Sure, but doctors also have to first go through a decade of protracted schooling where they depend on student loans and stipends and come out with considerable debt. Then even when working as an attending, doctors have many more expenses than the regular Joe like administrative staff, malpractice, and the like. Many doctors are struggling to stay financially soluble.

"I wonder if the real problem/dissatisfaction is the inequity between primary care and specialists."

Primary care is particularly hurting. But don't worry, you'll be in the excellent care of graduates from third world medical schools in your old age. Or possibly a Nurse Practitioner, like you had in elementary school.

"4. If drs. could deduct what you call "charity care" would enough drs do it? Not enough drs are willing to treat medicaid patients now, so what makes you think more will if its purely free care?"

Doctors already take Medicaid patients knowing the revenue of the visit will not cover the costs. It may even cost them money. Charity care makes the point clear that healthcare is not a right because a right cannot be something that comes at the expense of another party. It is charity. Doctors are generally of an altruistic bent and will take in a patients for charity's sake - they just won't do it to the point that it will harm them to do so.

And if enough doctors aren't willing to do sufficient pro bono work then it rests on our nation's numerous charity organizations to do the important duty of helping sick people pay their medical bills.

I think it's of extreme importance to not confuse the public by turning what is supposed to be charity into a Robin Hood entitlement.

Anonymous said...

The threat not to take insurance is a bit hollow. How many drs can survive on the few who can afford pay as you go.

BTW - Do Drs. in countries with some form of socialized medicine or universal health care report the same dissatisfaction as U.S. drs?

Orthoprax said...

Anon,

"The threat not to take insurance is a bit hollow. How many drs can survive on the few who can afford pay as you go."

It's not hollow. Doctors will accept cash - the patient can go fight the insurance companies for reimbursement.

"BTW - Do Drs. in countries with some form of socialized medicine or universal health care report the same dissatisfaction as U.S. drs?"

Not sure. I'm not aware of similar surveys done in other countries. If you can find good data that could prove interesting.

Anonymous said...

Of course doctors will accept cash. The problem is not too many patients have the cash to pay upfront. Perhaps for the occassional $100 office visit, but not for any procedures, lab work, imaging. Further, if medicine became a cash business, a lot of basic primary care patients will go to cheaper minute clinics staffed by nurse practitioners. That may be a good thing for the occasional strep throat or poison ivy, but not good for more complex diagnostics or managing chronic conditions.

In short, in a cash only world, I anticipate we would see a lot of doctors spending a lot of time reading medical journals and polishing their stethoscopes, but not treating patients.

Orthoprax said...

Anon,

"Of course doctors will accept cash. The problem is not too many patients have the cash to pay upfront. Perhaps for the occassional $100 office visit, but not for any procedures, lab work, imaging."

I expect doctors would be willing to accept credit card as well. There are many solutions to these minor problems which don't involve the doctor having to waste time running after owed reimbursements.

As long as insurance programs underpay doctors and make it a hassle to collect for services rendered I don't see why doctors ought to deal with them. Find a decent insurance model and doctors would be happy.

"Further, if medicine became a cash business, a lot of basic primary care patients will go to cheaper minute clinics staffed by nurse practitioners."

Um, this is *already* happening. Governments favor this because they're cheaper than doctors.

"In short, in a cash only world, I anticipate we would see a lot of doctors spending a lot of time reading medical journals and polishing their stethoscopes, but not treating patients."

Doubtful. If there's a market then there's a market. Most people are not so poor that they couldn't afford basic medical care. You think doctors were just sitting around doing nothing in the 1950s?

Anonymous said...

Saying "let them pay by credit card" is like Marie Antionette saying "let them eat cake."

Orthoprax said...

"Saying "let them pay by credit card" is like Marie Antionette saying "let them eat cake.""

Nonsense. You think a month isn't enough time for them to get reimbursement from their insurance company?

Garnel Ironheart said...

Okay, speaking from a position of experience working for many years in the Canadian everyone's covered system:
You will never have a Medicare free for all in the U.S. The reason is because you have to pay for an army. We in Canada don't have much of one so we can afford the billions that national health care costs. You cannot afford the trillions it would take to pay for your army AND universal medical care. So don't worry, it won't happen.
Secondly, doctors are whiners. Sorry but we are. Ask a doctor at the bank cashing his $50000 monthly paycheque if he's happy and he'll complain about the taste of the red wine at last week's Department reception.
Third, we know this is true because, let's face it, doctors are the smartest people in society and if medicine is so bad, how come we haven't all bailed out into easier professions with more secure incomes?

Orthoprax said...

GI,

"You cannot afford the trillions it would take to pay for your army AND universal medical care."

Canada's spending on the military as a proportion of GDP is about 1%. US spending is about 4%.

Canada's spending on healthcare as a proportion of GDP is about 10%. US spending is about 15%.

Since the US *already* spends more than Canada does on healthcare it stands to reason that we could afford a system like what exists in Canada. The extra 3% of GDP on military spending isn't what's holding us back.

"Third, we know this is true because, let's face it, doctors are the smartest people in society and if medicine is so bad, how come we haven't all bailed out into easier professions with more secure incomes?"

They have! Who's going into primary care now?

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