Are specialists responsible for the collapsing US medical system?

[Joe Richards]

Sorry not sure what happened with the quotes.

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[Joe Richards]

Friend,

I understand economics, your point, and follow what you are saying -- and even went so far as to say that I agree with you; I am simply saying that you overestimate the impact that the reimbursement negotiations have across the board, for everyone within any specific specialty. Again, I am only speaking from the perspective of a high cost surgical practice perspective; what you suggest would be much easier to do in the setting of general dermatology where the patient, payer, disease mix, and cost per encounter is significantly different.


I have argued for years that the highest compensated time per hour that a physician can spend is the time spent going over contracts and negotiating more favorable fee schedules. The returns on the time invested in this endeavor will be multitudes higher than even your best paid procedure. It is important for every doc to be aware that we see more of the last dollar that we collect compared to the first, and every percentage point of dollar squeezed out of these negotiations is a dollar that goes in your pocket (likewise, every dollar that gets cut is a dollar out of your pocket).

I will stand by the statement that the ultimate effect of these negotiations is likely quite less than you imply, the degree to which will vary from practice to practice and locality to locality based upon payer mix and local workforce dynamics. I believe that one flaw in your assumption is that is requires the existence of a significant discrepancy between the fee schedules of private insurers -- something that is not necessarily the case. Given the small number of insurers in most markets, everyone has identified the really poor payers and have either renegotiated better rates or are non-par with them. Of the widely accepted insurances, there exists little variation in their respective fee schedules; therefore, dropping the lowest paying one does not generate significant returns by filling those slots with another insurance that pays roughly the same. Given the fact that the vast majority of plans now contract on a % basis of Medicare, we even have a harder time carving out specific codes that we would like to protect.

We spend hours going over EOB's, combing through insurances, etc, and attempting renegotiations on a quarterly basis. Someone gets the axe once or twice a year. I do this because I believe that it is a necessary portion of running a healthy business (and I like it a lot), but I cannot say that I enjoy any advantage whatsoever over a well run, well positioned primary care office.... if people lose their dermatologist they don't cry all that much -- if they lose their "doc" they get tore up... and that is where the power ultimately lies.

If you still believe, however, that I am missing the boat somehow, please detail how one should go about it... and explain to me how someone can convince a 3rd party payer that they should pay higher than 125% or 150% of Medicare... especially when they already have other providers on their panel and really do not care if you continue to be par- with them or not. This is some information that I would like to know... and I would also like to hear how it can be done without collusion.

Dermatologist can negotiate fees because there aren't a lot of them out there. PCP's have a much harder time negotiating.

If you are part of a large group then you have some power because of the large patient base but if you are part of a small practice you can negotiate but you're not going to see much come out of it.

A solo dermatologist can set up shop, do business and in a year or so will have more patients than he knows what to do with. An FP trying to do the same will have a very difficult time unless he is in a rural or semi-rural setting and even then it may be difficult.

He can choose to do one of those low overhead type practices where he answers the phone, sees patients and does everything else but not everyone is cut out for that or want to practice like that.

 

[deleted87716]

Not every practice can do that. You may be in a large practice and have the ability but others may not.

Everyone has the ability to say "no" to a crappy fee schedule. Few, however, have the guts.

Besides Mid-levels will be happy to do it for less. At some point the insurance company will see that they don't need someone who charges them more because they have others.

That's the part you don't seem to understand...mid-levels don't cost insurance companies less than physicians. Mid-levels typically see fewer patients, order more tests, and over-refer to specialists, which actually makes them more expensive, even in a staff-model HMO like Kaiser.

http://nurse-practitioners.advanceweb.com/Editorial/Content/editorial.aspx?CTIID=761

In our September issue, ADVANCE reported on nurse practitioner layoffs in the Virginia and Washington, D.C., Kaiser Permanente regions. News of another shift in employment affecting nurse practitioners employed by Kaiser hit at the end of September --- this time in Hawaii. In late October, ADVANCE learned that NP positions were being shuffled in California as well.

A letter to all Kaiser Permanente employees in Hawaii stated that approximately 90 positions would be eliminated by Nov. 15 --- this includes about 18 nurse practitioners in primary care and pediatrics. Kaiser Permanente is one of the largest employers of NPs in Hawaii. (After the planned adjustments, Kaiser will have at least 29 on staff.) Fourteen new NP positions will be created in specialty care areas for the nurse practitioners who were laid off.

A message to employees from Janet Liang, president of Kaiser Permanente Hawaii, and Geoff Sewell, MD, president of Hawaii Permanente Medical Group, attempted to explain the reasoning behind the layoffs:

"In 2008, we will be redirecting our financial resources to increase access to primary care physicians, expand facility hours, strengthen clinical programs in prevention and wellness, and create more welcoming environments across all of our facilities. Additionally, through a number of nonpersonnel cost-saving efforts, we are significantly reducing expenses. These savings will directly benefit our customers with more competitive rates," Liang and Sewell wrote.

 

[MOHS_01]

Dermatologist can negotiate fees because there aren't a lot of them out there. PCP's have a much harder time negotiating.

If you are part of a large group then you have some power because of the large patient base but if you are part of a small practice you can negotiate but you're not going to see much come out of it.

A solo dermatologist can set up shop, do business and in a year or so will have more patients than he knows what to do with. An FP trying to do the same will have a very difficult time unless he is in a rural or semi-rural setting and even then it may be difficult.

He can choose to do one of those low overhead type practices where he answers the phone, sees patients and does everything else but not everyone is cut out for that or want to practice like that.

Joe,

While it is true that there are relatively fewer of us out here, the rules of the game do not significantly change -- true negotiating clout does not exist unless you are either the only game in town or the dominant game in town, and even then you are really only quibbling over over +/- 5-10% over market average for the locale (if most insurers are paying at 110% MC you will not be able to negotiate 145% rates unless you have a very strong negotiating position, which most do not).

The only real option that it leaves is to become non-par and hope that patients call and request your addition to their panel, which does provide some leverage in the process; otherwise payers are happy for you to be non-par as their costs are lower. I believe that the flawed assumption on everyone's part (mine included initially) is that payers really want & need us on their panels. I am no longer sure that is the case. Again, as someone pointed out earlier, when one is a high cost procedural specialist, the ability to go non-par is limited when compared to low cost per encounter operations.

Now the case can be made that, if one is non-par, his or her income could increase significantly; this is only true if you are willing to charge patients greater than what you should justifiably receive from your average insurance company, which is something that I will not do.

I believe in a fair transaction price, nothing more, nothing the less. The fact that some payers today pay above that price while many pay below that level is the product of a marketplace that I inherited. The entire "cost shifting" argument, in my opinion, is an accounting argument that was artificially created to pacify and appease physicians who continue to be screwed by MC & MA; now the Blues, UHC, any HMO, etc. This argument could only have validity if the price differential was intentionally created; that may have been the case historically (as my history is fairly short), but that most definitely does not seem to be a valid argument today.

 

[deleted87716]

true negotiating clout does not exist unless you are either the only game in town or the dominant game in town, and even then you are really only quibbling over over +/- 5-10% over market average for the locale (if most insurers are paying at 110% MC you will not be able to negotiate 145% rates unless you have a very strong negotiating position, which most do not).

That's not even what I'm talking about. There are plenty of physicians in my area who have accepted commercial contracts that pay below Medicare rates. We've been offered those contracts ourselves. Of course, we didn't participate. Why anyone would is mind-blowing. Individual physicians don't have much clout when it comes to negotiating with third-party payers, but if everyone (without collusion) had the intestinal fortitude to "just say no" when they're obviously being asked to drop their pants and bend over, things might eventually improve. As long as people keep signing these crappy contracts, payers will continue to test our limits.

 

[MedicineDoc]

These are the kinds of things I see on a routine basis that reinforce the reality of the current specialists dominated system. A patient with anemia scoped from above and below with negative stool hemoccults and no iron studies performed. An 87 year old with severe occlusions of the carotid arteries seen by carotid ultrasound the previous day (with a ejection fraction of 15-25% who is otherwise doing well and wants no part of any kind of surgery) being given an MRA of the carotids and aortic arch by vascular surgery. Said MRA agrees with the ultrasound findings and offers no additional information and regardless of the findings the 87 year old patient adamnatly against surgical intervetion of any kind. A pulmonologist sees said patient as he also has CHF with pulmonary edema and recommends nothing but more chest x-rays and nebs for pulmonary edema/COPD/CHF which patient is already being treated for by Family practice. Meanwhile cardiology sees the patient and recommends giving him a beta blocker and ace inhibiter with in the face of a BP of 100-120 systolic and nearly completely occluded internal carotids. Basically recommending something that is likely to stroke the patient out. Cardiologist then comes by the next day and bitches the patient out for not being on hospice care when he is was then doing well and ready for d/c home albeit on home oxygen. This stuff happens daily. These people need to make money and they will find something useless to do to make money if there isn't something useful to do.

 

[GassiusClay]

Exactly.

Ditto for Ophtho. Ditto for Radiology. Ditto for Gas. How long are these residencies? are they more than 4 years, 5 at the most?

An FP who does, say, a sports medicine or OB fellowship does 4 years.

I will give you cardiothoracic surgery, or any surgery, really. Those guys and gals work very hard and should be compensated fairly for the sacrifice and the hours they work.

But the other above-mentioned "lifestyle" specialties are among the cushiest residencies around, and the shortest time committment in training for the amount of compensation in practice.

MOHS, if you believe what you say above about time committment in residency being the justification for higher salary, how do you justify yours when compared with others who spent the same amount of time in training but worked a whole lot harder and many more hours while getting that training, but who make a fraction of what you make?

This is not being confrontational--I really want to understand the logic.

I'd really like to know how the amount of compensation is justified for the amount of work or value to the patient for those specialties. If I control their hypertension and diabetes, ophtho has nothing to do for my patients. Radiologists can often help seal a diagnosis, but they can't do it alone. Someone has to order the right test and do the right workup and care for the patient and keep them alive. Why do those folks get paid less under our system?

And furthermore...how do we assign "value" to the patient...?

If value is awarded to the one who steps in and plugs up the holes on a patient who is already a catastrophe because they either didn't take advantage of or didn't have access to good preventive care in a medical "home" (and yes, I believe in it--it hasn't been invested in properly--how can we expect it to solve all the problems in a few years??)...it just seems backwards to me.

It's one thing for an FP to claim that his/her work has its demand, and then it's another thing to claim that the above mentioned specialties aren't difficult. I can guarantee that you would have incontinence within milliseconds if a patient crashed in front of your eyes. I see it all the time on codes. A bunch of internists wanting to know about the history of the patient while the BP is not obtainable, pulse is faint, etc. Too much thinking and not enough logical action. Some are just standing around and not determining what can be done in the next 3 or 4 minutes to turn this person around.

This happens in the OR but we have more monitors in place that allow us to predict what may happen before it actually does. Have you ever transfused 18 units of blood in 1 hour? I assume not. Now, please compare my easy residency to your job. What's so easy about it? Or is it just pre-conceived notions and jealousy?

You want FP/IM/Peds to earn more, that's cool. But if you consider other people's job easy, then others will throw out how easy your job is in many ways. I can say that intern year was FAR FAR easier than now. I had time to think of a plan and discuss things on rounds. No life or death maneuvers in seconds kind of thing. Big big difference. If you want to compare a viral syndrome visit to a healthy young person getting a superficial mass excision under light MAC, fine. But even the simpler surgeries can be crazy based on the surgeon.

On another note, radiology is hard. When most of you guys order tests and your reason is something stupid like cough, it makes their job harder. I like to give them a story so they have an idea of what to look for and comment on rather than a vague visual analysis. You know they get pissed when an FP or IM orders tests and doesn't really have a purpose and are even more annoyed when you think you can read it better than they can.

 

[MOHS_01]

That's not even what I'm talking about. There are plenty of physicians in my area who have accepted commercial contracts that pay below Medicare rates. We've been offered those contracts ourselves. Of course, we didn't participate. Why anyone would is mind-blowing. Individual physicians don't have much clout when it comes to negotiating with third-party payers, but if everyone (without collusion) had the intestinal fortitude to "just say no" when they're obviously being asked to drop their pants and bend over, things might eventually improve. As long as people keep signing these crappy contracts, payers will continue to test our limits.

I understand now... and we are saying the exact same thing. Carriers come at us all of the time with sub-MC rates which we either: 1. return to sender for correction of "typos" or 2. fax back thanking them for the good laugh. Why anyone would even consider signing these contracts when they have patients booked that afternoon is beyond me... I can understand the fear and apprehension of not having enough business at startup for a solo guy who starts his practice on borrowed money without institutional backing (like I did), but even I would not sign anything below MC, and would start dropping my lowest paying folks as soon as I was booked out more than one week.

I tell them to piss off if their rates fall below a certain percentage of MC (my pre-set floor); this rate does vary between geographic locations.

If PCP's cannot reasonably drop these insurers without fear of going broke, then I have underestimated the PCP shortage... and we all need to rethink this mid-level provider situation.

 

[MedicineDoc]

It's one thing for an FP to claim that his/her work has its demand, and then it's another thing to claim that the above mentioned specialties aren't difficult. I can guarantee that you would have incontinence within milliseconds if a patient crashed in front of your eyes. I see it all the time on codes. A bunch of internists wanting to know about the history of the patient while the BP is not obtainable, pulse is faint, etc. Too much thinking and not enough logical action. Some are just standing around and not determining what can be done in the next 3 or 4 minutes to turn this person around.

This happens in the OR but we have more monitors in place that allow us to predict what may happen before it actually does. Have you ever transfused 18 units of blood in 1 hour? I assume not. Now, please compare my easy residency to your job. What's so easy about it? Or is it just pre-conceived notions and jealousy?

You want FP/IM/Peds to earn more, that's cool. But if you consider other people's job easy, then others will throw out how easy your job is in many ways. I can say that intern year was FAR FAR easier than now. I had time to think of a plan and discuss things on rounds. No life or death maneuvers in seconds kind of thing. Big big difference. If you want to compare a viral syndrome visit to a healthy young person getting a superficial mass excision under light MAC, fine. But even the simpler surgeries can be crazy based on the surgeon.

On another note, radiology is hard. When most of you guys order tests and your reason is something stupid like cough, it makes their job harder. I like to give them a story so they have an idea of what to look for and comment on rather than a vague visual analysis. You know they get pissed when an FP or IM orders tests and doesn't really have a purpose and are even more annoyed when you think you can read it better than they can.

You must realize if you break down alot of what your saying it sounds pretty ridiculous. The have you ever transfused 18 units of blood? I'm pretty sure the nurse transfused the blood after someone else brought it and the surgeon stopped the bleeding right? Additionally, ACLS protocol is performed by all kinds of medical professionals daily. Also, a chest x-ray for chronic cough with no known reason is pretty legit. Why don't you ask your friendly neighborhood pathologist specializing in oncology about ordering chest x-rays for chronic cough? They think there aren't enough ordered. I heard one bitching the other day about it. You don't need a freaking story to see a coin lesion and I'm pretty sure any generalist can interpret a chest x-ray and aren't overly interested in the radiologist's report. At least in this dimension maybe not in your dimension on the other side of that black whole.

The breadth and amount of knowledge possessed by good family medicine doctors is obviously something you don't understand. They are some of the most knowledgeable doctors in existence. FM docs have a big picture view. They are capable of doing at least 85% of most specialty work with a better understanding of how it fits into the overall health of patients and their multitude of medical problems.

As the specialist become more specialized and closer to a technician the Generalist holds true to the publics concept of what a doctor is which is someone capable of managing illness not some specific component of illness.

 

[lowbudget]

Specialists rely on generalists as much as generalists rely on specialists. You have good specialists and generalists as much as you have bad specialists and generalists.

Our system is set up for patients to make choices. Some patients prefer to have "their doctor" whom they trust guide them; others want the opinion of multiple doctors. There are patients who don't trust their PCP's, and there are patients who never follow through on specialty referrals.

Everyone's different. It's hard to devise a system because it assumes we know the answer. Which we don't.

What I don't appreciate is when specialists (happened to be a Moh's surgeon) bad talk the very physicians that send them business which happened to me once. Something about going to a "real" dermatologist, despite the fact that I found her BCC on an annual physical, shaved it, and sent her to him after I made the diagnosis. I don't mind if patients want to tap into my network on who a good dermatologist is. But if they want to insult me, they need to quit being a cheap skate and buy an insurance plan that gives them access to specialists without a referral. I said it more politely though. And with a smile.

Or my favorite, when a specialist tries to render an opinion on a primary care issue so outside of their scope. Talk about screwing over the patient. I would rather the patient go to Google Medical School than listen to some specialist thinks they know what they're talking about when in fact they don't, or haven't kept up with the literature.

I once had an anesthesiologist rip me a new butt hole about being too aggressive with his father with borderline sugars with meds. When I explained that given the patient's exercise compliance and cardiac risk from Metabolic Syndrome, it was reasonable to be aggressive with borderline sugars. The anesthesiologists said: "What's Metabolic Syndrome? I've never heard of it..."

I once had an endocrinologist ask me what medications I use to control a Type 2 diabetic with near normal A1c's. She said she wasn't used to seeing patients with near normal A1c's and wasn't sure.

I once had a neurologist on board on a hypertensive stroke patient who, in retrospect, didn't know what he was doing when fiddling around with oral BP meds, ended up with hypotension, extending the patient's stroke. I didn't get a chance to cancel his orders in time.

I once had a orthopedist who tried fiddling around with a patient's diabetes meds. Scary because I got called multiple times for hypoglycemic episodes.

Just because doctors are "specialists" don't mean they know what they're doing...

I don't blame the patients; they don't know any better, although some of them ask for it. Those who prefer to have 10 doctors managing their 5-10 problems (i.e. specialists who refer to other specialists) figure out soon enough that their medical bills get out of control and NO ONE knows what the hell's going on with them.

What can you do? I just let patients figure it out and come to me to bail them out. In the meantime, I do my best to offer what I can. I can't take care of you when I'm not in the loop.

 

[lowbudget]

And on a side note, just because a specialist has a corner on the market, doesn't mean the patient is getting good care. From my experience, when patients don't have a choice in their doctors and feel trapped, they become increasingly disgruntled, untrusting, and more likely to cause trouble.

A good family doctor knows who the good doctors in the area are. I send my imaging to radiologists whom I trust. I send my dermpaths to dermpaths whom I trust. I send my patients to doctors whom I trust. I send patients to surgeons who have better outcomes and better recoveries.

Unfortunately, for patients, there isn't much choice in the anesthesiologists they use or ER doctors they use. It's Russian roulette with those guys. The good news is most of those guys are pretty smart. The bad news is bad things happen even to the smart doctors. Maybe that's why their liability is so high. For the patients who want the most qualified person taking care of them, I'm surprised that they would tolerate mid-levels in the ER or OR taking care of them. I think it's because they don't have a choice.

But I predict that'll change very soon. In the US, we value our choice of doctors and are willing to pay escalating prices to find one that we like. With so many people going into anesthesia and ER, it'll get more and more competitive to win the hearts and minds of patients and the doctors who take care of them.

And unlike primary care, anesthesia and ER are dominated by large groups who secure exclusive contracts with hospitals. So individual doctors don't really have as much power as they think they do. If they get let go by their group... well... you're screwed.

At the end of the day, as much as primary care is just "a job", I'm happy with where I am. For some of the specialists who make as much money as they do, they sure spend a lot of time complaining of one thing or another... it's quite sad actually.

 

[MOHS_01]

What I don't appreciate is when specialists (happened to be a Moh's surgeon) bad talk the very physicians that send them business which happened to me once. Something about going to a "real" dermatologist, despite the fact that I found her BCC on an annual physical, shaved it, and sent her to him after I made the diagnosis. I don't mind if patients want to tap into my network on who a good dermatologist is. But if they want to insult me, they need to quit being a cheap skate and buy an insurance plan that gives them access to specialists without a referral. I said it more politely though. And with a smile.

I trust that you no longer refer to him/her? Out of curiosity, how did you hear about the doc talking negatively about you? From the patient? Unless it was a very specific quote, please try to keep in mind that patient's quite often employ a very strange filter for information, hearing what they want, ignoring what they don't like, and place their own spin on everything. It is often an unconscious process, although a few (and they, over time, become very easy to pick out) regularly twist things for some gain.

One thing that I tell patients all of the time when asked questions outside of skin problems --

"I don't know. I just don't know enough about that to say."

I think that too many docs have a hard time admitting that.

As a side note, when a PCP sends me someone in referral for a biopsy proven skin cancer, I send the patient back to them for their routine exams after the wound is well healed. Sometimes they come back to me for their skin checks, sometimes they don't, but that is purely patient preference (and I do not encourage them to come back to me).... also, on low risk patients, I often tell them that they do not need to come to me for a routine skin exam if they already see their PCP on a regular basis and who is comfortable with doing the skin exam... I see no need in duplication of services. I do point out to them, however, that if they or their physician ever has a question or concern, they know where to find me.

 

[deleted87716]

It's one thing for an FP to claim that his/her work has its demand, and then it's another thing to claim that the above mentioned specialties aren't difficult.

She never said they weren't difficult. She simply questioned the income disparity. All fields are difficult unless you've been trained in them.

I can guarantee that you would have incontinence within milliseconds if a patient crashed in front of your eyes.

ACLS isn't exactly rocket science, y'know.

As I like to point out, family physicians save lives every day. We just don't wait until the last minute.

 

[andwhat]

She never said they weren't difficult. She simply questioned the income disparity. All fields are difficult unless you've been trained in them.



ACLS isn't exactly rocket science, y'know.

As I like to point out, family physicians save lives every day. We just don't wait until the last minute.

this may or may not be true.


Quote:
I can guarantee that you would have incontinence within milliseconds if a patient crashed in front of your eyes.


not true, not true at all.

Gassius Clay
It's one thing for an FP to claim that his/her work has its demand, and then it's another thing to claim that the above mentioned specialties aren't difficult. I can guarantee that you would have incontinence within milliseconds if a patient crashed in front of your eyes. I see it all the time on codes. A bunch of internists wanting to know about the history of the patient while the BP is not obtainable, pulse is faint, etc. Too much thinking and not enough logical action. Some are just standing around and not determining what can be done in the next 3 or 4 minutes to turn this person around.

This happens in the OR but we have more monitors in place that allow us to predict what may happen before it actually does. Have you ever transfused 18 units of blood in 1 hour? I assume not. Now, please compare my easy residency to your job. What's so easy about it? Or is it just pre-conceived notions and jealousy?

You want FP/IM/Peds to earn more, that's cool. But if you consider other people's job easy, then others will throw out how easy your job is in many ways. I can say that intern year was FAR FAR easier than now. I had time to think of a plan and discuss things on rounds. No life or death maneuvers in seconds kind of thing. Big big difference. If you want to compare a viral syndrome visit to a healthy young person getting a superficial mass excision under light MAC, fine. But even the simpler surgeries can be crazy based on the surgeon.

On another note, radiology is hard. When most of you guys order tests and your reason is something stupid like cough, it makes their job harder. I like to give them a story so they have an idea of what to look for and comment on rather than a vague visual analysis. You know they get pissed when an FP or IM orders tests and doesn't really have a purpose and are even more annoyed when you think you can read it better than they can.
__________________

please refrain from bad mouthing a specialty.

 

[MOHS_01]

I can TOTALLY TOTALLY picture MOHS bad talkin PCPs performing the exact same procedures that he is going, while he gets paid more for them.
This is insecurity.

Man, I really don't get you sometimes... rant on some things, then demonstrate some lucidity... only to go back to ranting? I have defended PCP's from day one, in practice and on here; even if we do not always agree on the reimbursement structure, relative degrees of expertise, etc all of the time...

Oh,

1. There are no PCP's that I am aware of doing "the exact same procedure" that I do.

2. If they do, 80% or better would be on MC patients -- therefore we would be reimbursed equally for the vast majority of cases.

3. Insecure? The only thing that I find myself insecure about is the predictability of my future reimbursement and thus pay....... trust me, encroachment by general dermatologists, much less outside specialties, is not a huge source of anxiety for me after two years of practice. At the beginning, maybe, but not now.

 

[andwhat]

Man, I really don't get you sometimes... rant on some things, then demonstrate some lucidity... only to go back to ranting? I have defended PCP's from day one, in practice and on here; even if we do not always agree on the reimbursement structure, relative degrees of expertise, etc all of the time...

Oh,

1. There are no PCP's that I am aware of doing "the exact same procedure" that I do.

2. If they do, 80% or better would be on MC patients -- therefore we would be reimbursed equally for the vast majority of cases.

3. Insecure? The only thing that I find myself insecure about is the predictability of my future reimbursement and thus pay....... trust me, encroachment by general dermatologists, much less outside specialties, is not a huge source of anxiety for me after two years of practice. At the beginning, maybe, but not now.

I am sorry, you as an example, not you in particular, sorry that I misworded that. Our hometown Derm guy doesn't allow the residents to TOUCH his patients. Even University residents have been ushered aside to watch him do procedures. Craziness. You have to admit though, that there are Specialists against Primary Care doing the same procedures. I was using you as an example, apologies once again.

My issue though is with Gasius Clay.
Please refrain from insulting members of this forum, that have absolutely nothing at all to do with you.

 

[MOHS_01]

Understood, no apology required for misunderstandings.

Play ball.....

 

[lowbudget]

As I like to point out, family physicians save lives every day. We just don't wait until the last minute.

OTOH, Blue, if you wait until the last minute, it only lasts one minute.

 

[lowbudget]

I can guarantee that you would have incontinence within milliseconds if a patient crashed in front of your eyes.

I once had an anesthesiologist (different one) rip me a new butt crack when I ran into a difficult airway. Just so happens that I'd been on a roll and didn't have an airway I couldn't get if my (FP) interns couldn't get. But this one was just difficult. Anyways, he laid into me on how I'm not qualified to intubate and wanted to know who my attending was. Wrote all this crap into the chart. For all the codes, airway, and central lines I'd done (and taught), I'll call anesthesia or surgery, what, like once every 6-9 months at most for one I couldn't get or rescue. Anyways, I'm guessing he was one of those brash recent residency grads who I had never seen during my time there.

I told my attending in the morning. And we all had a good laugh during morning report...

Because he had no idea what was about to hit him...:
I got a copy of his schedule, got his pager number, and put out a memo to the entire residency program to page this poor bastard for all codes, pre-codes, and house officer evaluations for CP/SOB per his request since we weren't "qualified". We, then escalated it, to hammer paging him 5-8 times (instead of once) to these calls. Right after we hammer page him, we'd throw in the tube, no problem. We'd wait until he got to the room and say, "that's ok, we got it." We'd wait 1 hour later when he was back in bed to ask the page operator to page the anesthesiologist to "Cancel Airway". I mean, we'd light up his pager!!!

He'd be busy in the middle of the night in the OR and would respond that he can't come to the code/pre-code/whatever. So, the nurses would get pissed at the anesthesiologist, writing into their note that he wouldn't respond to 5-8 pages to a code, and report him to Admin.

LOVE IT. We did that for a couple of months, and I got in trouble for hammer-paging-delay-canceling him with my PD. But I didn't care because he had nothing to say. What? I'm not supposed to page the anesthesiologist for airway? Multiple times if he doesn't respond? Freakin' even the ICU charge nurses had our backs. We didn't see him on the call schedule soon after. The back story being that he wasn't cut out to work at our lowly FP-resident-run community hospital and his private group transferred him to a (s)LOWER acuity community hospital.

So, the only "incontinence within milliseconds", I'd say, would be how much we pissed on this anesthesiologist who made a brash mistake to go up against the FP army of residents who do so much around the hospital... who could've made his life easy.

EVERYBODY knows: You teach us, we don't call you. Perfect symbiosis... but this guy...

Hehehe... I love telling that story.

 

[andwhat]

I once had an anesthesiologist (different one) rip me a new butt crack when I ran into a difficult airway. Just so happens that I'd been on a roll and didn't have an airway I couldn't get if my (FP) interns couldn't get. But this one was just difficult. Anyways, he laid into me on how I'm not qualified to intubate and wanted to know who my attending was. Wrote all this crap into the chart. For all the codes, airway, and central lines I'd done (and taught), I'll call anesthesia or surgery, what, like once every 6-9 months at most for one I couldn't get or rescue. Anyways, I'm guessing he was one of those brash recent residency grads who I had never seen during my time there.

I told my attending in the morning. And we all had a good laugh during morning report...

Because he had no idea what was about to hit him...:
I got a copy of his schedule, got his pager number, and put out a memo to the entire residency program to page this poor bastard for all codes, pre-codes, and house officer evaluations for CP/SOB per his request since we weren't "qualified". We, then escalated it, to hammer paging him 5-8 times (instead of once) to these calls. Right after we hammer page him, we'd throw in the tube, no problem. We'd wait until he got to the room and say, "that's ok, we got it." We'd wait 1 hour later when he was back in bed to ask the page operator to page the anesthesiologist to "Cancel Airway". I mean, we'd light up his pager!!!

He'd be busy in the middle of the night in the OR and would respond that he can't come to the code/pre-code/whatever. So, the nurses would get pissed at the anesthesiologist, writing into their note that he wouldn't respond to 5-8 pages to a code, and report him to Admin.

LOVE IT. We did that for a couple of months, and I got in trouble for hammer-paging-delay-canceling him with my PD. But I didn't care because he had nothing to say. What? I'm not supposed to page the anesthesiologist for airway? Multiple times if he doesn't respond? Freakin' even the ICU charge nurses had our backs. We didn't see him on the call schedule soon after. The back story being that he wasn't cut out to work at our lowly FP-resident-run community hospital and his private group transferred him to a (s)LOWER acuity community hospital.

So, the only "incontinence within milliseconds", I'd say, would be how much we pissed on this anesthesiologist who made a brash mistake to go up against the FP army of residents who do so much around the hospital... who could've made his life easy.

EVERYBODY knows: You teach us, we don't call you. Perfect symbiosis... but this guy...

Hehehe... I love telling that story.

ha ha that story is amazing......

 

[lowbudget]

I can TOTALLY TOTALLY picture your average corner Dermatologist bad talkin PCPs performing the exact same procedures that he is going, while he gets paid more for them.
This is insecurity. I have seen GI docs do this incessantly about FM docs, complaining that they get to do colonoscopies at some University institutions. Of COURSE this is bad for their business, but not the patient -- and this is what would put them out of business.
Its all politics.

No. It's about money. That's all it's ever been about.

Do you think dermatologists want to fill their waiting rooms with Medicaid patients?

How many GI doctors are fighting you to do colonoscopies in the uninsured? Please. I would love it if a scope-scope-scope GI doctor fought so ferociously and violently to take care of the poor. Call me, y'all! Operators are standing by.

The sooner we all admit it's about money, the sooner we can stop rearranging the furniture on the Titanic we call our health care "system".

 

[andwhat]

As a CA-1

--------------------------------------------------------------------------------

I'm sure its too early to b#tch about how anesthesia is treating me so far since I can say most days are pretty good (6-6) with free weekends.

However, I'm finding the catering business to be a little annoying. Last year, I catered to patient's unreasonable demands. Now, it's dumb***** surgeons telling me the patient is not relaxed when clearly 0/4 twitches, ETCO2 waveform doesn't show anything suspicious, and I gave 10 of vec like 10 minutes ago during the induction period. Then I give a placebo. Let me give 2 more. Blatantly not. And suddenly the patients relaxed 3 minutes later. I think this pisshole just does it on purpose because he sucks at putting trocars in and resistance = not relaxed.

This catering to surgeons who are stupid is starting to get annoying. I know when I joined the anesthesia club, that I wouldn't get credit for a lot of stuff like thanks for fixing me up doc, but I'm SORT of okay with that. I don't demand that. I however demand that I am treated like a peer when you take 3 hours to do the case and not listen to stupid talk about your mediocre understanding of physiology. It's not just fluids.

Sure prelim medicine was Q4 with social support issues, but I felt like I had equal input maybe since most of attendings at the private hospital knew less than me. And the CRNA issue doesn't help because I don't want to be b#tch just to be one of them 4 years down the road.

I read the BOW YOUR HEAD thread, and found some inspiration. What about the rest of you CA-1s? And CA-3s? And attendings?

Then again, I can't see a place in medicine that offers any degree of real independence. Anybody up for starting a small business ?



I am not sure Gasius Clay, what you are doing here.
Please do not take out your personal frustrations out on this forum. We have nothing to do with you, or your lifestyle.

 

[deleted87716]

Next time you are angry, and want to throw a fit, please take it out somewhere else.

Maybe both of you should consider doing that. This personal pissing contest has nothing to do with the original thread.

 

[GassiusClay]

My point is that people think that what they do is the sh## and mock MOHS for doing derm is okay, but then don't want somebody like me injecting a little bit of reality that all your colleagues aren't super physicians like you running a whole hospital. I VALUE the role of the FP but when an FP thinks he/she is better than another doctor based on their "complete global" knowledge, it's insulting and therefore don't be surprised if someone doesn't insult you back. Some of you might not be saying it outright even though others have. Things go both ways even if it's "your" forum. FPs lack certain skills and specialists in other ways. There is NO doctor who can cover ALL functions in even FP run hospitals. I suspect some people are hyping up everything they do, which goes for GI, cards, and other docs too.

You constantly complain about how hard your job is versus a dermatologist (calling him a pimple popper), and it is surprising that a resident is arguing with a guy really practicing derm about clinic management and market forces. MOHs actually knows what's going on because he is actually doing it. Once again, don't complain if I slight you while you think your superior knowledge allows you to sling mud at him and others. As for pay differences, that should be based on the nature of acute risk balanced in with chronic risk associated with the task/procedure. I'm perplexed that someone thinks a clinic visit is worth more than a instant decision scenario (even applies to healthy patients under the stress of surgery). I only use anesthesia examples since I don't want to downgrade the complexity of one of the other easy specialties that I don't deal with daily.

On another note, the transfusion of 18 units is done by me in the OR, not anyone else. Giving the pressors is done by me, not someone else. I don't get to write orders and tap my feet. I draw it up, calculate, titrate. Fun times sometimes. As for ACLS, it might be efficient your hospital, but certainly not the zoo we come to on call. And placing a tube can be taught to a high school student, but when it can't be done right the first time, it's time to think of alternative options instead of jamming it down (which we have laxity for in codes since many people coding don't have great outcomes). And there are non-code intubations where use of certain OR drugs helps in facilitating a smooth intubation without sympathetic surges which become important in people with cardiac disease.

I actually understand what an FP does on a daily basis and value it, but it seems many of you have ZERO idea what a radiologist, anesthesiologist, ophthalmologists do on a daily basis. I even underestimated the level of risk involved in anesthesiology based on my fourth year rotation. I have no beef with FPs in general, but some of you are just plain militant and too high and mighty about your specialty (which will be the undoing of all medical professionals and then comes the mid-levels). To be honest, I have thought about my days of doing primary care and at many times feel open to a change. I personally don't give a squat about the money as long as my loans are paid back. I don't have this huge lifestyle need. Remember, mo money mo problems.

 

[andwhat]

My point is that people think that what they do is the sh## and mock MOHS for doing derm is okay, but then don't want somebody like me injecting a little bit of reality that all your colleagues aren't super physicians like you running a whole hospital. I VALUE the role of the FP but when an FP thinks he/she is better than another doctor based on their "complete global" knowledge, it's insulting and therefore don't be surprised if someone doesn't insult you back. Some of you might not be saying it outright even though others have. Things go both ways even if it's "your" forum. FPs lack certain skills and specialists in other ways. There is NO doctor who can cover ALL functions in even FP run hospitals. I suspect some people are hyping up everything they do, which goes for GI, cards, and other docs too.

You constantly complain about how hard your job is versus a dermatologist (calling him a pimple popper), and it is surprising that a resident is arguing with a guy really practicing derm about clinic management and market forces. MOHs actually knows what's going on because he is actually doing it. Once again, don't complain if I slight you while you think your superior knowledge allows you to sling mud at him and others. As for pay differences, that should be based on the nature of acute risk balanced in with chronic risk associated with the task/procedure. I'm perplexed that someone thinks a clinic visit is worth more than a instant decision scenario (even applies to healthy patients under the stress of surgery). I only use anesthesia examples since I don't want to downgrade the complexity of one of the other easy specialties that I don't deal with daily.

On another note, the transfusion of 18 units is done by me in the OR, not anyone else. Giving the pressors is done by me, not someone else. I don't get to write orders and tap my feet. I draw it up, calculate, titrate. Fun times sometimes. As for ACLS, it might be efficient your hospital, but certainly not the zoo we come to on call. And placing a tube can be taught to a high school student, but when it can't be done right the first time, it's time to think of alternative options instead of jamming it down (which we have laxity for in codes since many people coding don't have great outcomes). And there are non-code intubations where use of certain OR drugs helps in facilitating a smooth intubation without sympathetic surges which become important in people with cardiac disease.

I actually understand what an FP does on a daily basis and value it, but it seems many of you have ZERO idea what a radiologist, anesthesiologist, ophthalmologists do on a daily basis. I even underestimated the level of risk involved in anesthesiology based on my fourth year rotation. I have no beef with FPs in general, but some of you are just plain militant and too high and mighty about your specialty (which will be the undoing of all medical professionals and then comes the mid-levels). To be honest, I have thought about my days of doing primary care and at many times feel open to a change. I personally don't give a squat about the money as long as my loans are paid back. I don't have this huge lifestyle need. Remember, mo money mo problems.

not a resident, not your business to attend to, and not at all impressed. Superior knowledge??? Show me where I said that even once. It has nothing at all to do with knowledge. It is about compensation issues.
Again, if you are frustrated with your personal circumstances, as obviated above, please do not take it out on forums that have nothing at all to do with you.
I love your quote "most attendings knew less than me"
That is just hilarious.

I however demand that I am treated like a peer when you take 3 hours to do the case and not listen to stupid talk about your mediocre understanding of physiology. It's not just fluids.

Sure prelim medicine was Q4 with social support issues, but I felt like I had equal input maybe since most of attendings at the private hospital knew less than me. And the CRNA issue doesn't help because I don't want to be b#tch just to be one of them 4 years down the road.
When most of you guys order tests and your reason is something stupid like cough, it makes their job harder


Then again, I can't see a place in medicine that offers any degree of real independence. Anybody up for starting a small business
wow so let me get this straight here, the Surgeon is stupid, the Patients are stupid, you are far superior to IM attendings. FM docs are stupid.

 

[lowbudget]

I VALUE the role of the FP but when an FP thinks he/she is better than another doctor based on their "complete global" knowledge, it's insulting and therefore don't be surprised if someone doesn't insult you back. Some of you might not be saying it outright even though others have. Things go both ways even if it's "your" forum.

It's the rhetoric, not the reality, that's troublesome for most (or me). Sometimes, perceptions gains life of its own and becomes reality. That said, sometimes, there's a reason why perceptions are there in the first place.

What people don't get is that it's not about specialists or generalists. We're all on the freakin' same team: we take care of patients.

But when you put a wad of cash in the middle of the floor and say, "ok, educated people. Society trusts that you will govern yourselves" like we do in medicine, you'll see a lot of people (including myself) act like it's the last time they're gonna feast.

FPs lack certain skills and specialists in other ways. There is NO doctor who can cover ALL functions in even FP run hospitals. I suspect some people are hyping up everything they do, which goes for GI, cards, and other docs too.

Yea, I think that goes without say. No disagreement here.

 

[lowbudget]

You constantly complain about how hard your job is versus a dermatologist (calling him a pimple popper), and it is surprising that a resident is arguing with a guy really practicing derm about clinic management and market forces. MOHs actually knows what's going on because he is actually doing it.

Well... don't give him that much credit (sorry MOHS). MOHs and Blue Dog are arguing about apples and oranges. Same, but different.

MOHs is talking about "variable costs", costs that can change depending on how busy a practice is. That's what he was talking about in terms of % of Revenue. Example: 1) Electricity- when a patient is in the room, turn the lights on; when a patient leaves, turn the light off; or 2) Paper- the more patients you see, the more paperwork is generated.

Blue Dog is talking about "fixed costs", costs that remain the same no matter how busy your practice is. Example: Rent- It's $20/sf whether you there or not; or Salaries- It's $40k whether your receptionist answers phone calls or not.

Can fixed costs become variable costs? Yes, in the long run. Example: If you're receptionist isn't working, lay them off; or, if your phones are super busy, you hire another receptionist.

I don't really know what they're arguing about; because to me, they're talking about different things.

I think Joe Richard's and MOH's debate is interesting... personally. Joe Richard is right that generalists don't have the negotiating power as specialists. That's because general medicine, on the MICRO level, is competitive: lots of providers and low barriers to entry. (Now, whether or not general medicine is *perfectly* competitive is one topic I would love to debate... but I'd rather hold out and just see y'all bastards in the marketplace.)

When you specialize, there's less and less providers and the barriers to entry gets higher and higher (due to skills, or available technology, or privileging, or branding). When this happens, it's called a monopoly (or oligopoly), which by definition is inefficient. And I think this was SophieJane's point as the OP.

The caveat here is that it is very hard to maintain a monopoly forever. This is because demand almost always overwhelms the ability for monopolies to provide (example: pediatric orthopedists where you have to wait for months in order to get in).

Or, technology evolves and it topples monopolies. Example: stents over CABGs. That said, doctors who adopt monopoly-toppling technology can stay remain in a monopoly role. Example: Nuclear stress over exercise stress. Or, as the NPR piece is saying: Caths over exercise stress.

Most technology comes out of specialized medicines where they test success or failures. How many of us general medicine people do that? Not many. That's because we hate research.

I think MOH's is right... on the MACRO level. That Medicare/Medicaid serve as a monopsony (and if you've never heard of it, look it up). And because there's generally a monopsony or oliopsony (at best), doctors can't negotiate infinitely... that there's only so much negotiating power that a specialist has before it becomes unreasonable. There is an upper limit. And therefore, even for specialists, it's not just a price business... but also a volume business... if I'm not misunderstanding you... And, as primary care doctors, we control the volume of business that specialists see... you see?

 

[lowbudget]

I actually understand what an FP does on a daily basis and value it, but it seems many of you have ZERO idea what a radiologist, anesthesiologist, ophthalmologists do on a daily basis. I even underestimated the level of risk involved in anesthesiology based on my fourth year rotation. I have no beef with FPs in general, but some of you are just plain militant and too high and mighty about your specialty (which will be the undoing of all medical professionals and then comes the mid-levels).

Well, I don't agree with this statement.

At worst, I think we do it better than other specialties because by definition, by design, by the nature of our training, we ROTATE with all those specialties you listed AND MORE, which is more than I can say about other specialties.

We at least train, maybe not hard core, but at least we train with all in all those specialties AND nurses, PT/OT, hospice, chaplain, and families. And we do it in the ICU, in the OR, in the ER, in the nursery, in the NICU, on Med/Surg, in Rehab, in the clinic, in SNF, in LTAC, in the stroke unit, in the dementia unit, in the cardiac unit, in nursing homes.

We do it in L&D, in abortion clinics, in inner-cities, in rural clinics, in the mountains, in the 3rd world, in posh dermatology spas, in counseling centers. We do it on the football fields, at school clinics. We do it in communities, in academia, in City Halls, in health departments, in board rooms, and in advocacy groups.

Freaking A... we even go to patient's HOME's to take care of them, if not when we get out, then definitely during training.

Why? Because we're required to. Why? Because someone, somewhere, at sometime thought it was important to do so.

Where do ER doctors train? In the ER, ICU, maybe OR and med/surg. Do they train elsewhere? No... why? Because it's not important to them. And that's why they make inappropriate admissions and inappropriate discharges. And that's why their liability is so high. And that's why they practice so much defensive medicine that they burn out and quit.

I mean, ask yourself: Where do anesthesiologists train? Where do OB/Gyn's train? Where do IM or Peds train?

I think we do it better because we get out of our front porch and we travel the world. And if that's the reason why it feels so nice to come back home after being on the road, then so be it.

 

[deleted87716]

MOHs is talking about "variable costs"

He is?

Blue Dog is talking about "fixed costs"

I am?

I don't really know what they're arguing about

I didn't know we were arguing.

 

[lowbudget]

You're hilarious. Yea, you were:

If it costs me $100,000 to run my practice, and I generate $50,000 in revenue, what's my overhead? It's $100,000. The net "profit" in that scenario would be a negative $50,000 (a loss). If I generated $200,000 in revenue, what's my overhead? The answer is still $100,000. My net profit, however, would be $100,000.

And... he was:

Blue,

You lost me, buddy. My statement in no way constitutes a commentary on the reimbursement structure that we have today -- facts are facts and math is math -- and by virtually anyone's definition overhead is the cost associated with providing a service, which is a simple mathematical calculation based upon revenue generated minus cost incurred divided by revenue... a good deal of our costs (the vast majority in my practice) are fixed in nature (and includes staffing requirements), and therefore the variable that falls most within our control is revenue generation.

<snip>

As an aside, general, medical dermatology has the same overhead as primary care as a general rule -- approximately 55%. In practices that provide a strong mix of surgery, path, with or without cosmetics, our typical overhead runs anywhere from a low of 40% (rare) to 50% (most common according to AAD figures)... with MGMA "good" performers holding at around 45%.

 

[deleted87716]

You're hilarious.

I'm here all week, folks. Please...try the fish.

And... he was

I think we were trying to say the same thing.

 

[MOHS_01]

I thought that we were trying to say the same thing -- it was an internal terminology error (on my part and acknowledged), whereas I was equating "overhead" to a percentage rather than total costs. As far as I know, we were not arguing over fixed vs variable -- but the vast majority of costs associated with delivering any given volume of services is largely fixed; carried further, incremental costs for providing increasing volumes of services are low up to a threshold which requires increased staffing or providers, and variable costs constitute a fairly low input to total costs for my practice at least... all of which translates into the point that I had tried to get across -- for me, the single greatest factor in the equation that determines my ultimate pay is collections, largely driven by volume, with a disappointingly low return on my "negotiated fee schedule premiums" due to payer and disease mix.

If you want to be a purist, then I will readily admit that much of what I lump into "fixed costs" would classically be better defined as "variable costs", and when I use the term "variable" I am actually referring to "incremental"... For example -- electricity, hourly staffing, telephone, etc all have the potential to vary from month to month, but in practice they do not (or only negligibly so), so I lump them into fixed as they have been stable to within a percentage point or two on a month to month basis. Billing, bookkeeping, and consulting managerial fees are either fixed in price or percentage of receipts, so they are predictable. The same holds true for the various insurance costs. Medical supplies, advertising (if you do it), office supplies, etc, while fairly stable, do tend to increase/decrease with volume and days worked, so I consider these costs "variable costs".

 

[deleted87716]

the single greatest factor in the equation that determines my ultimate pay is collections, largely driven by volume, with a disappointingly low return on my "negotiated fee schedule premiums" due to payer and disease mix.

Yep.

 

[Joe Richards]

The loss on your collections could actually be thought of as a variable cost since the amount you collect every year can change from year to year.

 

[Joe Richards]

Mr. Clay VS Mr. Lowbudget.

Winner = draw

Time has run out in this UFD (ultimate fighting doctors) championship.

Both of you are basically saying you demand respect from each other and need each other.

Hug, kiss and make up.

 

[GassiusClay]

Man, I really don't get you sometimes... rant on some things, then demonstrate some lucidity... only to go back to ranting? I have defended PCP's from day one, in practice and on here; even if we do not always agree on the reimbursement structure, relative degrees of expertise, etc all of the time...

Oh,

1. There are no PCP's that I am aware of doing "the exact same procedure" that I do.

2. If they do, 80% or better would be on MC patients -- therefore we would be reimbursed equally for the vast majority of cases.

3. Insecure? The only thing that I find myself insecure about is the predictability of my future reimbursement and thus pay....... trust me, encroachment by general dermatologists, much less outside specialties, is not a huge source of anxiety for me after two years of practice. At the beginning, maybe, but not now.

Andwhat = self-glorified physician.

As for me not liking surgeons, I hate surgeons who are like andwhat, meaning I'm so good that I only matter in patient care.

As for me thinking patients are stupid, I think a lot of them are and then there are a lot who care but have to share resources with failures which doesn't help them get ahead if they come from financially difficult backgrounds. I don't believe in universal insurance. I believe in universal insurance for people who demonstrate responsibility of their own bodies.

As for me thinking I'm smarter than my intern year attendings, I do believe so because I actually cared to analyze patient needs and give them something that fit their budget and behavior. I didn't push things on them and I tried to meet them halfway versus showing up for a few minutes, writing a scribble after someone else's note, and asking for consults to deal with simple issues rather than tackling them on their own. It's just pure laziness, which may not represent you since you are superior to all other physicians.

As for my easy CA-1 year, ah..doofus I take call at least 5 times a month so it may not be Q4, but I don't get consult months where I may only work 40 hours in a week. Plus, you get some degree of breathing room versus my 40 minutes (10 for a break, 30 for a lunch). The rest of the time I pay attention second to second. Good anesthesiologists don't read in the OR. That leads to an unrecognized problems that snowball into larger problems. I don't plan on doing an M&M. Vigilance has a whole other meaning.

As for people who believe that they are the only doctors needed in this world a.k.a andwhat, I give up. I can't convince so-called professionals who call other people a-holes even though they are the true a-hole. I don't rag on people who understand their limitations and acknowledge need for assistance. I do hate people who think they are so good that they are infallible a.k.a andwhat.

Essentially, andwhat has the complex of some physicians who find berating others of "lesser" skill to make up for not having their perceived free time, excess salary/cars/house, whatever. I've seen it enough from internists who think radiologists sit on their butt not reading the hundreds of studies that they ordered, transplant surgeons ragging on internists about how they don't understand immunosuppresants... Maybe andwhat wouldn't care if someone said he/she deserved a Porsche 911 GT3 or some other luxury item. Maybe he wants a monument "Best primary care provider in the world who can do everything a specialist can ON A FORUM."

Keep quoting and hating. Hopefully, you are not in charge of fixing healthcare.

 

[MOHS_01]

The loss on your collections could actually be thought of as a variable cost since the amount you collect every year can change from year to year.

Then my variable costs amounted to three solid kicks to the groin and two rabbit punches after Jan 1, 2008... I'd consider tapping out if I still did not have what amounts to a good job (as far as anything in medicine goes, at least).

 

[andwhat]

Andwhat = self-glorified physician.

As for me not liking surgeons, I hate surgeons who are like andwhat, meaning I'm so good that I only matter in patient care.

As for me thinking patients are stupid, I think a lot of them are and then there are a lot who care but have to share resources with failures which doesn't help them get ahead if they come from financially difficult backgrounds. I don't believe in universal insurance. I believe in universal insurance for people who demonstrate responsibility of their own bodies.

As for me thinking I'm smarter than my intern year attendings, I do believe so because I actually cared to analyze patient needs and give them something that fit their budget and behavior. I didn't push things on them and I tried to meet them halfway versus showing up for a few minutes, writing a scribble after someone else's note, and asking for consults to deal with simple issues rather than tackling them on their own. It's just pure laziness, which may not represent you since you are superior to all other physicians.

As for my easy CA-1 year, ah..doofus I take call at least 5 times a month so it may not be Q4, but I don't get consult months where I may only work 40 hours in a week. Plus, you get some degree of breathing room versus my 40 minutes (10 for a break, 30 for a lunch). The rest of the time I pay attention second to second. Good anesthesiologists don't read in the OR. That leads to an unrecognized problems that snowball into larger problems. I don't plan on doing an M&M. Vigilance has a whole other meaning.

As for people who believe that they are the only doctors needed in this world a.k.a andwhat, I give up. I can't convince so-called professionals who call other people a-holes even though they are the true a-hole. I don't rag on people who understand their limitations and acknowledge need for assistance. I do hate people who think they are so good that they are infallible a.k.a andwhat.

Essentially, andwhat has the complex of some physicians who find berating others of "lesser" skill to make up for not having their perceived free time, excess salary/cars/house, whatever. I've seen it enough from internists who think radiologists sit on their butt not reading the hundreds of studies that they ordered, transplant surgeons ragging on internists about how they don't understand immunosuppresants... Maybe andwhat wouldn't care if someone said he/she deserved a Porsche 911 GT3 or some other luxury item. Maybe he wants a monument "Best primary care provider in the world who can do everything a specialist can ON A FORUM."

Keep quoting and hating. Hopefully, you are not in charge of fixing healthcare.

You know what, I will indeed look past your several severe shortcomings and personal insults, because I shall not stoop down to your bevavior.
I will not insult you, in order to defend myself. Your writing truly speaks for itself, and you are incredibly unhappy, I can do nothing for you, nobody can in my opinion.
It is a compensation issue. Physicians should get compensated properly, based upon quality of work performed, and services rendered to the benefit of the patient.
That being said, is Prescribing Lipitor considered a "quality" piece of work? Yes of course it is, it prolongs life-- however it is not compensated nearly well enough.
Is preventive medicine important? Of course it is important, yet it is not compensated nearly well enough in my opinion.
Yes I run codes pretty much on an every other day basis some weeks, and I get a fixed salary which I am more than happy with.
That being said, do FM docs generate good income? Of course, usually over $200 K, which is not bad at all. However, the issue is, not being compensated fairly or equally across the board, considering the rest of the specialties.
It has nothing at all to do with Ego issues, who is smartest, who has what qualifications, it is pure and simply services rendered to the patient.
Do other docs need to get paid less? No of course not saying that -- however do Primary Care docs need to earn more based upon services performed for the patient's benefit.
Derm docs, and Orthapedic surgeons can see tons of patients in clinic, because they are usually brief checks, and minor in office procedures. This is how more compensation is generated, as well as billing correctly. Of course Ortho docs perform surgeries that generate huge revenue also.
It is very difficult for an FM doc to see that many patients, with multiple other issues. This is not the only problem with FM and payment. Declining insurance reimbursements is another critical issue that needs to be addressed all across the board.
Was that clear enough? Or do you need more personal ranting and raving and accusations towards me?
There are no doctors of lesser skill than me (or I would honestly hope not)
Oh my goodness, I am so good and important??? That is literally insanity.... I am shocked..
As for the rest of your writing, I could honestly care less, not worth reading. Talk to the wall
This is pure mudslinging, and I do not want any part of it.
As far as calling patients stupid, good for you! You will never ever talk to them, maybe a brief few seconds before they are rendered unconscious. You made the right decision with your life though, and thank goodness that you are indeed not talking to patients.
I dont care what other physicians have or do not have?? I honestly do not care what I even have or do not have?? I just think that there should be equality in payment for services rendered for the benefit of the patient.
I am really sorry for you, that you fail to realize that.

 

[secretwave101]

Now that I know how to kill - that is, spear, stomp, destroy, annhiliate - threads, I'm getting an itchy finger over this one.

Ju-eez people. What's with the personal salvos? Who came in here an waved away the hippie beads, kicked over our hooka and hijacked the FM thread vibes?

Tone it down, peeps!

Issues. Talk about issues.

 

[andwhat]

Now that I know how to kill - that is, spear, stomp, destroy, annhiliate - threads, I'm getting an itchy finger over this one.

Ju-eez people. What's with the personal salvos? Who came in here an waved away the hippie beads, kicked over our hooka and hijacked the FM thread vibes?

Tone it down, peeps!

Issues. Talk about issues.

it is about political issues, just somebody misconstrued my words, and misrepresented me... thats really disappointing.

 

[deleted87716]

Who came in here an waved away the hippie beads, kicked over our hooka and hijacked the FM thread vibes?

(I'm so glad I'm not a moderator anymore!)

 

[secretwave101]

Let's put it this way...if a good majority of your post involves CAPS and bold you're a little too keyed up for our folksy FM forum.

Switch to decaf, take a bounce or two on the core-ball...then give it another try.

 

[deleted87716]

Let's put it this way...if a good majority of your post involves CAPS and bold you're a little too keyed up for our folksy FM forum.

Increasing the font size should result in an automatic ban, IMO.

 

[sophiejane]

kids, kids, kids.

I leave the room for a few days and all heck breaks loose.

Consider yourselves warned. I can't believe we even have to say this, but really. Pipe down, or we shut it down

 

[GassiusClay]

Misconstruing? Degrading? Hmm...seems like it was okay not too long ago. I think it was post #22 or somewhere near that. But let's move on to compensation.

Compensation ideally would be based on impact on longevity and quality of life. However, the nature of a visit versus a procedure can be quite different. A procedure can be to a degree objectively evaluated because it leads to some endpoint in the near future. A visit on the other hand has factors that are doctor-independent. Patient compliance is the major one. So one can come up with a proper assessment and plan, but carrying it out is not all on the doctor's shoulders (at least it shouldn't be).

How does one reimburse fairly for a visit when the patient can affect the outcome by their own behavior? Is it fair to give a primary care physician in an impoverished area where the patient may not follow up regularly due to multiple reasons LESS than a primary person who has good, complaint patients who are generally better off? Now, the compensation part gets mucky. Both had a chance to make a solid impact, but maybe one has an easier path due to multiple factors not in the doctor's control. I can't see how it would be fair, creating a whole new mess for doctors who just happen to deal with more difficult patients.

I can agree that procedures regardless who they are done by should get the same compensation as long as one is adequately trained to deal with the complications, which most are not. You can't just pass it off to a specialist if you did something that the specialist can do on a routine basis. That's like passing off the baby when it goes in its diaper, but only wanting to be around it when it's pleased and happy. Specialists I assume would frown upon that especially if the compensation did become equal. So can it ever really be equal?

Plus, we haven't discussed risk as a factor. I will agree with a certain poster that treating shock and sepsis carries greater risk than removing a lesion on the skin in terms of acute response. However, we must also consider the risks of leaving behind margins that later could spread and lead to a bad bad outcome. So how do we find a balance in that? Usually, procedures are associated with greater acute risks versus counseling. Telling a patient to take a statin is not life or death in the next few hours kind of thing though has long-term impact. Doing a liver resection. Well...different. Should the people involved in that be reimbursed less because it's not preventive even though that might drive them up the wall at times? Hard to compare. Critical care kind of specialties (ICU, anesthesia, EM, some sections of surgery) deal with stuff that's not preventive all the time, but should they get less than primary care?

Move out of the realm of your specialty and see that this problem is never-ending. A simple solution or cause of the problem doesn't exist. Actually, there is one solution: the emergence of a sense of personal responsibility and acceptance of the idea of death amongst the American public. That cuts costs more than anything we could ever offer. But that's never going to happen. It's always our fault.

 

[J-Rad]

Switch to decaf...

I am deeply offended by this statement. Pure discrimination against the overly java-juiced!

 

[andwhat]

Increasing the font size should result in an automatic ban, IMO.

sure I will go ahead and sign off. Sorry for expressing concern over the future of Family Medicine. Thanks have a great day

 

[GassiusClay]

While most physicians will continue to believe that change requires sectarian violence, I have seen far less discussion on fine tuning funding of medical services.

Why haven't we dealt with Sustainable Growth Rate (SGR) yet?
A statement by a University of Chicago MD highlights something very important. Medical technology even simple CBCs and BMPs, instruments, and facility/personnel costs continue to rise. Funding has not. But the government seems to be okay with that $135,000,000 Raptor defending freedoms everywhere (also known as imperialistic BS).

Another interesting view on it is in this blog. It's certainly true that both primary care and specialty physicians cram people into shorter visits to increase volume as well as procedures. We are all running factories in one form or another unless our clients can afford to pay for 3 peoples time. I assume most physicians out there aren't in the 90210 zip code. So we have nasty cycle started by cuts leading to compensatory behavior creating more spending leading to more cuts. Maybe one day we can solve the problem by running people through a machine like in Idiocracy.

I wouldn't mind just getting a set salary for set number of hours that adjusts with inflation. Anything beyond that could be based on market forces. Think it's a good solution?

 

[Joe Richards]

While most physicians will continue to believe that change requires sectarian violence, I have seen far less discussion on fine tuning funding of medical services.

Why haven't we dealt with Sustainable Growth Rate (SGR) yet?
A statement by a University of Chicago MD highlights something very important. Medical technology even simple CBCs and BMPs, instruments, and facility/personnel costs continue to rise. Funding has not. But the government seems to be okay with that $135,000,000 Raptor defending freedoms everywhere (also known as imperialistic BS).

Another interesting view on it is in this blog. It's certainly true that both primary care and specialty physicians cram people into shorter visits to increase volume as well as procedures. We are all running factories in one form or another unless our clients can afford to pay for 3 peoples time. I assume most physicians out there aren't in the 90210 zip code. So we have nasty cycle started by cuts leading to compensatory behavior creating more spending leading to more cuts. Maybe one day we can solve the problem by running people through a machine like in Idiocracy.

I wouldn't mind just getting a set salary for set number of hours that adjusts with inflation. Anything beyond that could be based on market forces. Think it's a good solution?

What would you want that set salary to be?

200 K
300 K

One million or giZZZillion?????

Who would decide how much that salary is going to be?

You, somebody in a govt. office, someone from the AMA?

Really who would set that number?

 

[MOHS_01]

While most physicians will continue to believe that change requires sectarian violence, I have seen far less discussion on fine tuning funding of medical services.

Why haven't we dealt with Sustainable Growth Rate (SGR) yet?
A statement by a University of Chicago MD highlights something very important. Medical technology even simple CBCs and BMPs, instruments, and facility/personnel costs continue to rise. Funding has not. But the government seems to be okay with that $135,000,000 Raptor defending freedoms everywhere (also known as imperialistic BS).

Another interesting view on it is in this blog. It's certainly true that both primary care and specialty physicians cram people into shorter visits to increase volume as well as procedures. We are all running factories in one form or another unless our clients can afford to pay for 3 peoples time. I assume most physicians out there aren't in the 90210 zip code. So we have nasty cycle started by cuts leading to compensatory behavior creating more spending leading to more cuts. Maybe one day we can solve the problem by running people through a machine like in Idiocracy.

I wouldn't mind just getting a set salary for set number of hours that adjusts with inflation. Anything beyond that could be based on market forces. Think it's a good solution?

Buddy,

Strong out of the gates, faltered at the end...

I try real hard not to throw stones aimed directly at folks, but if I had one I would aim square at your forehead for that last statement (just to knock some sense into you). Salaries and hourly wages work well for different job descriptions; neither fit well with medicine. Medicine's current pay structure does create "relative winners and relative losers" through the devaluation of cognitive labors relative to procedures, but, fundamentally, it pays for productivity -- a basis that is fundamentally good and should not be abandoned. We need to find a way to implement quality measures within the current model; pay for quality and productivity. Salaries would not work well outside of a few specialties (where they are already quite prevalent); e.g. hospital based employees (hospitalists, ER, possibly anesthesia, rads, rad onc, path, and I'm sure that I missed a few). We have to incentivize both productivity and quality as defined by representative specialty board initiatives; this would be a much better approach than a strict outcome based approach toward reimbursement for it better accounts for the imperfect science that is medicine (i.e. you can do everything right and still have a bad outcome, non-compliance, willful neglect on the part of the patient, etc).

The reason that the SGR has not been addressed is that, given the very architecture of healthcare reimbursement, there simply is not enough revenue within the system to allow for its repeal.