<p>Reading this thread makes me realize just how far medicine has gone in the managed care direction, and the influence of the many institutions that come between doctor and patient. </p>
<p>At one point in time, that relationship was considered private and somehow sacred. Now, both doctors and patients feel that something is missing, but it makes sense considering how much that relationship has been altered and exploited. </p>
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<p>Of course I ‘get’ how it works. Do you get that the $5000 is not real, it is not an entitlement for the doctor? The doctor says I want 5k, the insurance company says 2.5K take or leave it. You take it, that becomes the price for that category of patients. The doctor is making money anyway, and the occasional rich guy, well that’s a bonus.</p>
<p>You also set your rates at whatever, $3000 per day. If you can’t fill up your days at that rate, and someone offers you 1.5K, especially for a good regular volume of business, you may well take it too.</p>
<p>There is something people need to understand about running a private practice that is different from many businesses. Let’s say you sell something (clothes, cars, whatever). Each salesperson is bringing money into the business. Out of that money is overhead- rent for the space, upkeep, utilities, advertising, and support staff- people who run the office. One can have more salespeople than support staff, all bringing in money and all those salespeople can be in the same store with maybe a small desk or cubicle as a car salesperson uses.Somewhere between what money comes into the business and what comes out is what the owner gets to keep.</p>
<p>In a doctor’s office, there is a large ratio of support staff per doctor or provider. Only the providers such as docs, PA’s. NP’s are able to bill for services and bring income into the practice. The rest of the support staff- secretaries, office managers, insurance billers, nurses, typists for medical records, are not people who bring income into the practice. However, they are essential parts of it, and should earn their salaries and benefits too. For every doc, there needs to be at least 3 support staff to do the billing, schedule appointments, nursing or medical assistants and office management. For every doc there needs to be an exam room, medical supplies, and an office to do personal work, dictations, phone calls and electronic medical records. Therefore a practice can’t function well with more docs than support staff and each doc requires extensive overhead costs. Out of that $3000 that appears to go to the doctor, he or she may keep only a fraction of it. </p>
<p>So what happens when insurance cuts a doctor’s fees? The landlord doesn’t reduce the rent, the supplies don’t get cheaper, and if the doctor tells the staff “sorry you get less pay this month” the employees would be in dire straights. Often they are hard workers who the doctor values and would not consider doing this to them. So, when insurance cuts fees it is the doctor who absorbs the loss. If a doctor made $3000 and after overhead, kept $1000, and insurance cut it to $1500, the practice would no longer be able to run. With inflation, overhead costs are rising, and doctor fees are diminishing. Many doctors are becoming employees of larger corporations and hospital because of this. </p>
<p>So, what happens to doctor autonomy and the personal aspect and satisfaction in the doctor-patient relationship? The same thing that would happen to a marriage if someone else told you how to relate to your spouse, timed it and coded it, and the insurance CEO, hospital administrator and other regulators were also sleeping in your bed. </p>
<p>Maybe if drs took the time to do their own scheduling as my naturopath does, they wouldn’t have the overbooking problems and could live on what they earn from the ins companies.</p>
<p>The naturopath doesn’t have nearly the amount of overhead a physician has and is far less regulated. Even if a doctor took the time from a practice to book appointments, there would still be the need for other staff. Billing and coding is a full time job. </p>
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When would that do that, exactly? Should they answer the phone themselves, too? And what are they supposed to do with the support staff that does the scheduling - cut them loose?</p>
<p>@Pennylane - great post #262!</p>
<p>Sorghum,
there are what are called “reasonable and customary charges” that are established by insurers based on the g]fees in the area. If the drs started charging the negotiated, discounted fees, instead of the full fees and then adjusting the negotiated fee later as it is done, then that changes the usual and customary charge and the rates get lowered even more. Its a process beyond the scope of this discussion.</p>
<p>“Of course I ‘get’ how it works. Do you get that the $5000 is not real, it is not an entitlement for the doctor? The doctor says I want 5k, the insurance company says 2.5K take or leave it. You take it, that becomes the price for that category of patients. The doctor is making money anyway, and the occasional rich guy, well that’s a bonus.”</p>
<p>The $5,000 IS real. That’s the reasonable cost of this procedure - not so doctor can buy his wife a diamond ring, but the reasonable cost of such-and-such procedure keeping in mind the doctor’s training, the malpractice he’s required to carry, blah blah blah blah. The choice being given to the doctor is - we’ll pay you $2,500 or nothing at all. No negotiation. Take it or leave it. </p>
<p>I think you haven’t a clue how NON-lucrative medicine is these days, unless you have someone who is a real genius at managing the office.</p>
<p>“Maybe if drs took the time to do their own scheduling as my naturopath does, they wouldn’t have the overbooking problems and could live on what they earn from the ins companies.”</p>
<p>Having a well compensated professional do what is a clerk’s job is a waste of resources. And I don’t think you are getting how much staff time is taken up with billing and coding. H, in solo practices, employs several people for whom that’s all they do, all the livelong day. Your naturopath doesn’t have that because, well, frankly, your naturopath is kind of a pseudo-medical professional. They don’t have nearly the regulations that a real doctor has.</p>
<p>Example: H bought a new mammogram machine. He was 2 days late in filing the appropriate paperwork with our state’s department of whatever, and got fined $16,000. Now, it’s completely on him that he failed to do so, he’s not making any excuse, but the point is - your naturopath doesn’t have to comply with regulations over big-time medical equipment and so forth because his or her scope is limited, because the training is so limited. </p>
<p>Well, I don’t think most of this is the doctors fault at all, but it is a mess. And, it’s not hard to find doctors who agree with that assessment, either.</p>
<p>And, the OP succeeded in getting what may have been the intent of the thread-- more Dr bashing. Happy?</p>
<p>Physicians used to not have as much staff.
You went to the hospital for X-rays instead of their office.
You had an ultrasound when really needed instead of every visit because they had it right there.
My pediatrician had a nurse give vaccinations but otherwise he did much of what a MA does. He even made house calls. This wasn’t a rural doc, but in a big city.</p>
<p>The operative word is USED TO, EK. Healthcare has changed, and there is now a third party, the insurer, sitting in the exam room with you.</p>
<p>It has changed. Evidence based medicine, managed care, 3rd party payers, malpractice insurance and lawyers, hospitals and more. Less time with patients, more reliance on labs. </p>
<p>No need to doctor bash. They are hurting too. Insurance was the camel’s nose under the tent. Health care is lucrative, but with so many piggies at the trough, every one is trying to hang on to a little bit of it. </p>
<p>When I was little, my pediatrician came to my house too. I didn’t like shots, but I wasn’t afraid of him. As time went on, the house calls stopped, but one could still speak to a doctor or a nurse. Now you call the office and you get a machine. A family friend was in the hospital, under the care of a hospitalist, who was technically good, but didn’t know her. The sparse nursing staff was busy with many patients. Hospitals are hiring less staff and squeezing the profit from that too. </p>
<p>As much as I am grateful for new technologies, medications and saved lives, I miss the days where the doctors and nurses could just talk to patients, even for a little while. I think they miss it too. </p>
<p>A new area called medical informatics has been formed, which trains people to manage all this computerized care. It has recently become a medical board specialty, so doctors will move into some management position too. The tide has changed and it won’t go back. I hope we all can hang on to some humanity here, </p>
<p>“Physicians used to not have as much staff.”</p>
<p>Yes, EK. When “billing” meant the receptionist at the front desk could stamp envelopes, when she wasn’t greeting patients. Not like today when it takes several clerks to deal with it all.</p>
<p>“You went to the hospital for X-rays instead of their office.
You had an ultrasound when really needed instead of every visit because they had it right there.”</p>
<p>Are you aware of what malpractice has done to health care?
And how do you assess “really needed” until after it’s done?
I don’t think you understand that if, for example, my H has <em>one</em> baby with a condtion that was detectable through ultrasound and he doesn’t find it ahead of time, his practice could be ruined - putting him and 12 employees out of work. In our state, they can go after personal assets too. </p>
<p>It often feels like a lose-lose situation Dr. wants to order a procedure? Some insurance companies require preauthorization form a third party subject to “medical necessity” (which is their definition of medical necessity, not a the treating Drs definition of necessary). So the Dr fills out forms or talks to a person on the phone who is not a physician. It is subject to the insurance company’s policys, not necessarily anything that makes medical sense as to why the procedure will be authed for situation A and not B. But thats another story. Then if denied, you appeal, and it goes on and on and the patient waits. Was this perhaps developed because there was an increase in unnecessary procedures? Probably. But was that possibly also tied to risk management and careful care to avoid litigation, also possible. Its a broken system… </p>
<p>I often have to wonder why anyone wants to be a doctor, because society expectation of a doctor is incredibly unfair.
<p>Expectations from doctors from patients are unbelievable. Medicine is a science of trial and error. Some stuff is textbook, much is not. Every patient that walks in the exam room is comprised of a myriad of health, emotional, social, religious (sometimes religion plays a factor in what medicine can be applied or not) factors - yet we want docs to fix us “1-2-3”?? </p>
<p>I work at a medical college. I look at many of our learners and say, “why”? Bless them on their path - it will ALWAYS be hard, always be trying, always be changing, often not be glorifying. </p>
<p>Sick people have the most awful attitude. Don’t smile, complaining, vomitting, coughing, sores, just ewww… But I guess it’s understandable because of the symptoms sick folks go through. Still, who wants to be around someone with a bad attitude?
Doctors. I can’t help but feel bad for some of the doctors. When patients are not vomiting or coughing on them or sticking their rotten body sores in the doctor’s face, they’re busy posting negative stuff about their doctors on CC.</p>
<p>You still want an apology?</p>
<p>You can assess " really needed" when the patient has an indication that suggests it is needed.
Most pregnant women should not be having routine ultrasounds. It shouldn’t be something that is done just because the doc has one & the insurance will pay for it & the expecting parents think it’s " fun"
Physicians aren’t the only ones guilty of this. I stopped going to my dentist because he wants to do yearly xrays even when I am having no problems. ( I also am suspicious of dentists, perhaps unfairly, because I still have zero idea how I contracted Hep B)</p>
<p>You’ve probably sensed that I am feeling fed up with the medical profession & you are right.
I have almost come to terms with the fact that psychiatrists are all about medication management these days, but I am not willing for my other docs to go that route.
I don’t want to just be prescribed a bunch of pills without knowing what the overall problem is.
Why do I have osteoporosis despite not having risk factors? Why do I have syncope? What can we do to mitigate the effects of hypermobility/ orthostatic intolerance?
Even though my insurance doesn’t require a referral to specialists, the specialists require a referral which means a visit to the primary trying to inform them of symptoms and why I think they are connected/need a referral to look further, in the 15 min or so allotted for my appt.
Why is it that when physicians don’t know or understand something, they dismiss it as unimportant?</p>
<p>I do respect the medical profession, but respect should go both ways.</p>
<p>I was two minutes late for my dentist appointment this morning…and I apologized.</p>