Doctors going broke

musicprnt · January 8, 2012, 12:37pm

Doctors are in a pinch with the decline in payments, especially from medicare (not surprising, given that in many practices, the population tends to be older, given that older people need more medical care). Health Insurance companies are grossly profitable, a couple of years ago the head of United Healthcare made 100 million in compensation…and to make those profits, health care companies, rather then making their money investing it, are doing so by creating larger profit margins, which comes from denying insured people coverage and cutting down what they will pay to doctors in their network.

Individual doctors are a dying breed, the family doctor like I had growing up with their own practice exists less and less. My doctor is part of a group with multi discipline doctors in the practice, and they just took it one step further, they have merged with a health care company that runs several hospitals in my area. The upside for them is the health care company handles the billing; the downside as already happened in this practice it is assembly line. I recently went in with a couple of complaints, I spoke to the doctor for 10 minutes, they ran some blood tests (he ended up giving me what passes for a physical these days), and he barely said anything, and when I talked to him about the results it was a 5 minute phone call that gave me a cursory description of the results (get exercise, lose weight…). I don’t necessarily mind, I tend to be pretty healthy, and there are several doctors and a nurse practitioner I like to see.

As far as losing the best and brightest because of declining income, I am dubious about that one. If money is the primary reason that people go into medicine then I wonder about them being the best and brightest to become a doctor, because what about having a passion to do what you are doing? How about caring about the people you treat, or wanting to make a difference? I also wonder if they are necessarily getting the best and brightest in medical school overall, is someone who gets great grades and high mcat scores necessarily the best and brightest, or just someone who knows how to game the process?

Put it this way, the most lucrative areas of medicine tend to be things like plastic and cosmetic surgery that generally operate outside insurance (other then reconstructive surgery and such), there is gold in them thar boob jobs and tummy tucks and so forth. And having some experience with them, and having people I know who have, many of them are nothing more then what you would expect, the kind of people you would see on “Nip and Tuck” and the like, out for the bucks and not exactly compassionate, caring physicians (obviously, there are those who are, I know of some reconstructive physicians who use the money they make from cosmetic surgery to do pro bono work to help disfigured kids and people too poor to get what they need, like reconstructive breast surgery after a mastectomy).

I have heard the same story for many years, I debated health care policy back in the late 70’s and there were already stories about doctors going broke, etc. I think that it is going to further be a consolidation of practices, mega groups, health care companies, etc, if in part to balance the power of the health insurance companies to use bureacracy to choke payments and so forth.

There is going to need to be reform, doctors do deserve to make a good living, given how hard it is, what they are doing and the cost of getting a med school education. Like with private health insurance, part of the problem is the malpractice insurance industry, where malpractice rates have soared to incredible levels. The standard line is it is a litiginous society, which is great for politicians and people to believe, greedy people, greedy lawyers, but that is also not entirely true (more on that in a bit). They put caps on payouts in california in response to claims from doctors and insurance companies, and guess what? malpractice rates continue to soar there. Analysis of data of large payouts, the ones we keep hearing about, have shown that there are very few of those, that the amount paid out in malpractice suits has actually decreased in many places, yet insurance continues to soar… and if you want proof of the real problem, take a look at the profiitability of the malpractice insurance areas of insurance companies, you will see, not surprisingly, their profits soaring. They have done what health insurance companies do, rather then take in premiums and make most of their profits from in investing it in markets and such, they are boosting their bottom line from charging higher and higher premiums.

And yes, unfortunately, whether real or perceived, there is a lot of cya going on. I had a sprained ankle, in the old days they would have xrayed it, seen there was no break, and had me soak it and keep in wrapped, etc; now they order an expensive MRI.

There isn’t any one answer, and I am not going to put forth a proposal because I am not sure what needs to be done, but the problem is systemic. The health insurance industry is a mess, the employer paid system is inefficient, and there are other problems. For example, last I heard something like 70% of health care costs are in maintaining the last month of life (which leads to all kinds of ethical issues), when someone doesn’t have a dnr and a team revives them, it can cost several hundreds of thousands of dollars. And yes, we need to reign in cya medicine as well or where every practice has an MRI and needs to recoup the cost of the machines and upgrades by scheduling tests and so forth…

musicprnt · January 8, 2012, 12:44pm

nurse practitioners are part of the solution IMO, in the sense that when it comes to routine medicine a NP is adequate, and a lot of medicine is like that. I had a bad case of poison ivy on my ankle several years ago, why should I need to see an MD when it is not exactly rocket science, or if I need a cut stitched? If a kid has symptoms that look like strep throat, and the strep spot test shows it is strep, it isn’t a big deal to diagnose and treat it, and so forth. Since NP’s tend to practice with doctors, if it is something they don’t know, they can turn it over to a physician. Studies of treatments between doctors and NP’s for routine care have shown that NP’s are just as effective, have the same mistake rates and such.

As far as NP’s misdiagnosing something, you think MD’s don’t? I have had stuff misdiagnosed, went to an MD and told me I had strep throat, turned out I had mono (figured that out when I reacted to the antibiotic they gave me). The real reason is much of what NP’s do is the bread and butter of MD’s and because NP’s make a lot less, they see it as cutting into their income.

whatever4 · January 8, 2012, 1:22pm

“Doctors going broke” is definitely not a problem in the Midwest. When I was younger, doctors in our community seemed to make a good income and lived comfortably, but their lifestyles seemed just slightly more lavish than that of their patients. In contrast, the physicians we are aquainted with now have vacation homes in spendy areas, take long trips to foreign countries, engage in expensive hobbies (mountain climbing, anyone?), have stay-at-home spouses, and occupy the nicest homes and drive the most expensive vehicles in the community. If they’re barely making ends meet, their “ends” are a lot different than ours.

floridadad55 · January 8, 2012, 1:37pm

It is easy for the government, for insurance companies, and for the public to declare:

“Medical costs are sky high----So let’s simply pay the doctors less”

But there will be long term consequences.

The socialized medical programs of Canada and the UK have some advantages, but also many problems.

Not all “one percenters” are bad.

Personally, I have no problem with a skilled surgeon or a skilled oncologist who went to school for a million years making a very good living. He or she deserves it.

Cost controls often result in counter-productive behavior.

Example----I read an article recently about the medical program in the UK. The public was getting outraged that you would go to the emergency room, and wait for literally hours to be treated. So the health service passed a regulation saying that all patients had to be treated within X amount of time after being admitted. So how did the government bureaucrats running the health system respond? What they did was to refuse to officially admit the patients to the emergency room. Instead, the patients were left outside of the hospital, in the parking lot, so that they didn’t count as patients yet.

mcat2 · January 8, 2012, 2:22pm

This sounds familiar in the high tech industry if we replace the word “NP” with “engineering students from overseas”, and “MD” with “engineering students from engineering schools in US.” Maybe NP-without-borders is the next step in order to make it even more cost effective and improve the bottom line of those in charge. As long as these imported NPs are from an English-speaking country, we may argue that they may be of the same quality, right? Maybe we can even establish some recruiting/certification semi-government organization right inside those English-speaking countries (where healthcare workers are paid less) to streamline the process in a cost effective way. BTW, doesn’t Cuba have surplus of doctors which are produced, either cheaply or cost-effectively depending on who you ask? Let’s import them! The globalization does not have to stop at trade only.

Last I heard about it, the end result is more engineering students from MIT head to Wall Street than go into the real engineering field. (Heck…MIT may be one of the top schools which have the most applicants from overseas, percentage wise. Maybe these students just use this school as a step stone to become a fat cat there.)

HImom · January 8, 2012, 2:26pm

There are a lot of ways of fudging #s…you can not count patients who come to the hospital but are just observed & NOT ADMITTED as hospitalizations to make your numbers better as well. Does that mean you are performing better & that the patients are getting better care? I don’t think so but it makes the numbers look like the hospital has greatly improved.

Personally, when things are pretty routine, my docs may just let me call them or email them & we can figure out whether I actually need to come in or they can just send a Rx for an antibiotic (or other thing I have been taking) to resolve the issue. I do not have any docs who have NPs or PAs, so don’t have personal knowledge of how well/poorly it would work. Have heard stories of folks who have been happy with these MD extenders & others who have had bad experiences.

cartera45 · January 8, 2012, 4:16pm

You can’t assume that MRI is a CYA move. It may be that the doctor owns an interest in the MRI machine. Imaging costs are the fastest rising of health care costs. Not surprisingly, the costs rose along with upward swing in doctors and practice groups buying the machines.

Such “self referral” became all the rage and was considered quite entrepreneurial. If questioned, the malpractice threat card is often played. Since the 90’s doctors have been prohibited from referring patients for imaging and lab tests to outside entities in which they have an interest. There was an exception created if they offered the service on site so they simply bought the machinery and set up labs on site. Radiologists were negatively impacted by this loophole.

The compromise in the new health care law was to require doctors to disclose to Medicare/Medicaid patients that they have a financial interest in the machinery and offer a list of alternative sites for treatment. That will have little or no effect on the problem of course.

HImom · January 8, 2012, 4:23pm

Yea, I still remember going to a cardiology practice, referred by my internist. EVERY visit, they tried to get me to have an EKG, even tho mine was PERFECTLY normal when it had been performed at my internist’s office just before the referral. They also kept wanting me to do more & more testing, that they did all in-house but never wanted to talk about the results (which were pretty normal as well). I fired them because they had NOTHING anywhere in my chart about the 30+ minute conversation I had with one of the partners about my risk for anaphylaxis, allergies and why I should NOT have a nuclear stress test or anything with sulfites. They were totally uncaring how long they made patients wait and VERY disorganized and arrogant. I told my internist they will kill someone or at least unnecessarily jeopardize their health by not making careful note of allergies (all the other docs put it in BOLD RED on the patient’s folder).

Sad thing is that this practice is VERY highly regarded & making TONS of money. You could never pay me to go back there.

couldbeworse · January 8, 2012, 9:49pm

I generally read more than post on CC and I love the way the threads wind around. As a long time PA (>30 years), I have to say some of the comments re: “physician extenders” are a little annoying esp from those who have had little to no interaction with one of us. I am now in an Internal Medicine practice with 8 MDs, 3 NPs and me. I completed an Emergency Med residency and spent 20 years in some of the busiest EDs in this country. There are many patient care issues in our primary care practice where I I am more skilled than anyone in our office. One of our NP’s spent 8 years with our local cardiology group, another is nationally certified in rheumatology. Our docs range from old hands to folks a couple years out of residency. We are all there to take care of our patients. Is it likely that I have misdiagnosed a patient? I am not stupid/arrogant enough to say no but my physician colleagues would answer likewise. We are a collegial practice and I am a physician assistant. That means when I have questions I go in the open doors of my colleagues for input on the best management steps for my patients. I would never practice where I did not feel I had a good working relationship with a physician whose skill I respected (been there, done that and it’s scary as hell).
Our practice recently “inherited” a large panel of medicare patients when several local practices decided they would stop seeing Medicare patients. We, of course, already had a large portion of our practice funded by medicare (hey, we’re Internal Medicine) but we accepted these patients as we knew they had few other options in our community. So recent (actually, it’s been a year in and year out factor to be dealt with) Congressionally mandated reductions in physician payment for services will, obviously, effect our practice income. You take a 27% across the line reduction and let me know how it would effect your business decisions. We don’t own the MRI or nursing homes or the local hospitals or pharmacies. Our income is from the professional service we provide. Each of us and our nurses spend a huge chunk of time interacting with insurance entities (insurance plans, pharmacy plans, medicaid, medicare, et al) trying to justify why we ordered a diagnostic test, a medication, a procedure, ad nauseam. It get’s old but it’s the only way to get our patients what we feel they need. 
Would I encourage young people to go into medicine? Yes. But not for the money. I think physicians in this country will always be well paid. I think the days of amassing personal wealth in medicine are done, however. You want a career that is challenging every day, that allows you to serve your community, that sharpens your critical thinking skills, that allows you entry into the lives of others and the chance to earn the friendship and respect of both patients and peers. Then, yes, medicine can be all that. But it won’t be easy. I would agree with GTalum that I have encouraged my own child that if she chooses this route, to go to Med school rather than PA school. I am darn good at what I do but I would be even better if had gone to medical school.
Wow, I’m not sure how I got from point A to point B. I maintain that the children sucked out my synapses! Sorry for the ramble.
As a final note, Icarus, when I graduated form my PA education >30 years ago I graduated from the Emory Physician ASSOCIATE Program. People were prattling then as well as now what our “name” should be. Most of us really don’t care. I started all those years ago convincing one patient (and MD’s as well) at a time that I would do all I could to provide appropriate and timely care for my patients. I’m still learning 30 years in and my goal is to continuing earning my patients’ and colleagues’ trust and respect. Ok, that is all.

cartera45 · January 9, 2012, 1:10am

Your type of practice is collateral damage to the effort to rein in some billing practices that got completely out of hand. At some point, the medical profession should have realized that they were killing their own golden goose. Bad times bring tough choices. Change really should come in good times so there can be planning and transition. We tend to wait for chaos to generate change.The insurance companies certainly were not going to make any changes. Nothing impacts them because of a little thing called premium increase.

Health care insurance, both private and through the “meds” needs a complete overhaul. I don’t see that happening until things start crashing, not just for the middle class and those in poverty, but for those in control. Since those in control are fairly insulated from crashes generally, it might take a revolution.

simba · January 9, 2012, 8:51am

“Your type of practice is collateral damage to the effort to rein in some billing practices that got completely out of hand.”

That is saying it mildly. My previous primary care was cheating outright. Our plan pays for free vaccination - $0 co-pay. Now if the doctor codes it as vaccination, he would get about $25 for flu shots. My doctor was billing them as office visits with flu shots as additional services - double dipping. He did not charge me the co-pays for office visits though. I let it slide for a year, but then he began aggressive in his scheme. After about six months he started sending us bills for the co-pays for those visits. He is not our primary care anymore.

GTalum · January 9, 2012, 10:18am

Simba, I suspect what your doctor was doing is probably not illegal, but a gray area charge that private practice offices are doing in order to stay profitable. Getting a vaccination is a nurse visit and does require staff time and effort.

I’m not saying it’s right. We don’t currently charge such things, but that is why we’re getting out of private practice. However, my primary care physician, who is still in private practice, uses a high priced health management consultation firm and charges in a similar way for vaccinations, missed office visits, and $35 for simple forms that require just a signature. I don’t want to charge such things as it effects the “good will” of your patients. Not having “good will” results in complaints to the medical board and law suits.

audiophile · January 9, 2012, 1:54pm

When you join the large group that purchased your practice, it will no longer be your decision, correct?

simba · January 9, 2012, 2:06pm

"Getting a vaccination is a nurse visit and does require staff time and effort. "

True, hence the payment of $25…The flu serums were/are free from Govt.

I like my current doctor who is in group practice. During the season, they hire a temporary needle sticker for a week or two and have all their patients come during that time.

GTalum · January 9, 2012, 2:17pm

Yes, it will not. But, with bigger group practices, reimbursements are better and often no need to “resort” to such measures.

Not for us. We order flu vaccines 6 months ahead and pay about $10 each. I doubt we break even charging $25. I wish I knew where to get “free” serum.

audiophile · January 9, 2012, 2:18pm

Do they also supply the syringe and needle? In addition, I assume a staff member made the appointment for you, the nurse brought you back into (hopefully) a private area, donned gloves and perhaps even wiped the injection site with alcohol or another disinfectant. I’m not up on the overhead of medical practice, but I suspect $25 wouldn’t cover that, let alone the nurse’s salary.

MiamiDAP · January 9, 2012, 3:10pm

I have experience when 5 min. appontment was charged at over $500. In addtion to not getting any help for my condition, I had to pay $265 out of pocket after insurance applied it to deductible. I would not say that this DO (yes, it was not MD, it was a DO) is going broke. I would say with 100% certainty that I will not be back to his office though. However, I do not think that he will notice that.
I am also aware of many who are working part time, yes, like 4 days / week by thier choice. 
It is hard to believe that any MD is working for nothing. If they get any compensation, it is still more than many of us, who have been unemployed several times in our lives or not getting any increases since forever because of years of downturn economy or uncertainty thrown down on businesess by government. MD’s are pretty much untouchable. I have never heard about unemployed MD and price of services are going up at much higher rate than inflation.

audiophile · January 9, 2012, 4:42pm

So different offices in the same geographic area get reimbursed at varying amounts by the same insurance co. for the same procedure? I agree, something’s wrong with this system!

cartera45 · January 9, 2012, 4:51pm

A doctor can always find work. It may not be where he/she prefers to live, but there are underserved areas of the country. The same is true with lawyers, believe it or not. I know everyone says there are way too many but, in some areas, there are literally none and people can’t do simple things like get divorced, file a simple bankruptcy or get a will drawn up. Most doctors and lawyers are not looking to live in Appalachia.

robyrm2 · January 9, 2012, 5:11pm

Cartera you seem to have a beef with professional folk who spend a lot of time trying to develop specialized skills. Why should someone who has spent 12-16 years of post secondary education and training have to go to an underserved area to practice their profession if they choose not to? Don’t you think they have ‘earned’ the right that car mechanics or electricians have to live where they want to live? To work for themselves if they want or with a large entity if they want?

I am an MD and have now practiced medicine in 3 countries with very,very different medical systems. If you want to see a model of less trained Doctors trying to do what you really only can do with more training, go to Indonesia. Heck, 18 years ago the former president even said (and I have the newspaper clipping)- ‘Our country has a problem with hypertension and kidney disease and we do not have enough doctors to take care of it. I have a solution. Instead of training these doctors for 3 years, we will train them for 2 and then there will be more doctors.’

If this logic appeals to you when you are sick, when you have a complex medical problem which requires more than ‘vocational’ training, then you should happily get on a plane to Jakarta. You might be interested to know that anyone in Jakarta who can rub 2 cents together to get medical care flies to Singapore, however.

Doctors going broke

CONNECT WITH US