Ramblings of an Emergency Physician in Texas
Dr. Wes: Dear Doctor: You Will Be Salaried
Dr. Wes has something he wants you to know…. And that I want every doctor to know, as well.
No related posts.
I don’t know if it will happen in my lifetime even though it is probably happening already, but these kinds of things we lead to very different expectations on both sides of the doctor-patient relationship.
We’re already seeing that it is harder to have a personal doctor, one that you exclusively or mainly have contact with. One time it’s this doc, the next another, or maybe a nurse practitioner, and you rarely see a doctor at all any more.
Healthcare is going to be delivered more and more by “health care systems”, where you are expected to have trust in the system, regardless of who you see. If we see this as an extension of hospitalist care in hospitals, one can already see that some are better than others, and even the best hospitalist tends to focus on the here and now in the hospital, and not so much or even at all about the long-term.
The other worry about system care is that in many cases it tends to be revenue-driven. If something is reimbursed, and especially if it’s reimbursed well, there is much competition. If it’s not, good luck finding care.
This will make the ED even busier. If I get paid the same for seeing 25-30 patients and getting home for supper vs staying late and seeing 35-40, guess which one I choose?
Agree. And, if I get paid the same rate for seeing 20 or 30 per shift, plan on waiting in the ED (yes, even more than now).
I saw this in military medicine. Completely salaried, and zero incentive to do more/faster/better. This caused a sort of “regression toward the mean” phenomenon with providers. Even the young-and-fresh “hard chargers” that came into the system would gradually slow down (or be worn down) by working harder and seeing more patients than their colleagues, or by constant resistance from the rest of the system (including ancillary services) who were unaccustomed to working at that pace.
And at 4:31? Every clinic is closed, the phones are shut off, and everything gets funneled to the ER… and don’t even mention weekends. Getting things done after-hours was particularly painful, with constant resistance from consultants, technicians, lab folks… basically everybody who otherwise had an 8:30-4:30 job. “Down days” and “family days” were the same way… ER gets crushed because everybody else is closed. Even if individual docs want to do more/stay late, they end up doing it on their own, because all the support staff are gone.
This is what happens in a salaried system… you’re getting paid the same amount whether you’re really “leaning forward” to take care of patients, or doing the standard, run-of-the-mill workload. Eventually you get tired, and say “screw this.”
So yeah… the ER will be inundated under Obamacare, as everybody else throttles back, limits their number of appointments, or cuts back on the number of days they’re in the office.
The ER doesn’t have that luxury… and if we’re salaried too, regardless of the number of patients we see, wait times are going to explode.
There will be no true free market in medicine until doctors walk away from the third party payor system in droves. Thus, there will be no free market in American medicine.
The hardest 6 months of my professional life was the decompression after 6 years of an insanely busy General Surgery residency at a major university program. I was assigned to a small midwestern AFB – then a missile base, now with a global tasking – with another surgeon overlapping for 6+ months.
After bouncing off the walls for a month, I finally set out to prepare for the boards that winter, went to regional grand rounds at a medical school in the big city on the horizon, and tried to deal with the slow pace.
There was in fact work to do, but the clinic staff and the nursing staff had a choke hold on scheduling and admissions, and no flexibility. Good people, but the priority was on staff education, safety talks, time off, mobility planning…ad nauseum, but patient care in any volume was secondary at best. Three hours in the OR twice a week was seen as punitive, and any belly case was cause for second opinions, demands for transfer, etc.
I saw no priority given to volume of care, and marked disincentives to expansion of services, etc. All of this, of course, was in line with the M.O. of the VA med ctr I did rotations at – excellent care, but doled out in small doses. The clocks got punched.
The paradox is that the legal profession holds out fee for service – time records – percentage of settlement/verdict incentives as necessary for a working justice system, and looks down the nose at the poor activity level of the salaried public defenders. They are the advocates for the injured and aggrieved. However, when physicians attempt the same logical analysis, we are held out as crooks stealing from the ill AND from society, rather that applauded as advocates for the ill and dying.
WHEN DID I BECOME THE REPRESENTATIVE OF SOCIETY RATHER THAN THE PATIENT???
John, you became the representative of society when your predecessors allowed your whole industry to become an adjunct of the federal government. That makes you not an individual offering professional services for sale, but part of a “system”, in which innumerable politicians, and often even physicians, promise all this care at seemingly no cost to those who seek it.
You are mistaken, and probably deliberately so, but I’ll let that go. We are the ones arguing for more market forces, more cost transparency, and less cost-shifting. What the federal government chose to do 40-odd years ago with Medicare isn’t our doing… so I’ll thank you to lay the blame where it belongs.
As far as “something for nothing,” it isn’t the medical profession whose TV commercials advertise “no cost if no recovery.”
“. We are the ones arguing for more market forces, more cost transparency, and less cost-shifting.”
Nonsense. Have you read the statements of your main lobbying arm, the AMA? You guys are the same ones who keep signing these same third party payer contracts, avoiding the free market.
Look at your industry. The AMA decides how many people even get into medical school, based on vague standards mostly related to limiting supply. 50% of the money in your industry is paid by the taxpayer. You’re asking the government to arbitrarily decide how much your mistakes are worth. You get your clients funneled to you from insurers who care more about your cost than your skill. You spend the bulk of your political dollars either trying to get the government, not the public, to protect you from liability or to throw a few more dollars at you. And you don’t even differentiate your value based on skill. You guys are so far removed from a “free market” it’s not even funny. And it doesn’t appear there is some great movement toward changing. Your lobbyists have no concerted effort to get away from the third party payment system, and the AMA is cautiously signing on with Obama.
“As far as “something for nothing,” it isn’t the medical profession whose TV commercials advertise “no cost if no recovery.”
Except for the fact you generally need an injury to have a case. You know, like those “lotto winners” with their million dollar malpractice verdicts. Who wants to trade places with them if they got something for nothing? You want their injury in exchange for their $1M? Anyone?
I want you to go back to the market like the rest of us professionals as much as anyone. But it’s clear that the vast majority of you have no interest in changing because you keep doing the same things expecting different results.
“What the federal government chose to do 40-odd years ago with Medicare isn’t our doing… so I’ll thank you to lay the blame where it belongs.”
Physicians weren’t on board with it then? More BS. They were, and frankly they were probably looking after their own interest. Payment scales were good, you didn’t have to worry about solvency, and you made a buttload of money. But you lost your profession for subsequent generations of physicians.
I wasn’t a physician 40 years ago… so you can stick that BS right in your ear, Matt.
As for the AMA being my lobbying arm, you stick that in your ear as well. I’m not a member, and never have been. In fact, most physicians aren’t members… but you already knew that.
Stop throwing sh*t.
You may not have been one 40 years ago, but you are one who keeps signing these same third party payer contracts which do not value your individual skills. You are the one who is doing little to nothing to take back your profession and as I said value yourself accordingly – actually, you’re one of many.
As to the AMA, you may not like it, but the public sees them as the voice of doctors, and they still are the largest by far of your lobbying organizations. And after all, your profession has empowered them to choose how many people get into medical school each year.
That’s not shit, that’s facts. Don’t get mad at me, be mad at your representatives. Be mad at yourself and your colleagues. I don’t want you to get paid that way. I don’t want single payer. I want you to have maximum individual freedom, I want you to act like a professional and be paid like one – and I don’t want you stifling others’ freedom by going to the govt. for damage caps, either.
You don’t “get” how this works, do you, Matt?
Hospital-based physicians like ER docs don’t get to choose many of our working conditions, including little things like whether we accept Medicare or not… or whether to have malpractice insurance or not. The hospital will mandated that we have those things… or we don’t work. Period.
As for the AMA, they have been losing power for years, as physicians have fled the organization, correctly determining that it doesn’t really serve their needs. And the AMA does NOT control medical school enrollment. They have a partial role in accrediting schools (along with the AAMC, which is made up of the schools themselves), but where do you get that they control enrollment? Do you think the AMA simply calls the school and tells the Dean how many slots he can have that year?
Alternatively, you can try to open more schools… but you have to build the physical plant, set up teaching programs at nearby hospitals, recruit faculty, get accredited, get funding… we’re talking years, and about a Billion dollars a pop in startup costs.
The AMA also doesn’t control residency slots, and it’s not their fault that there’s a primary care shortage. Those things are controlled by the government via CMS… and the “shortage” is simple economics; primary care is a grind, it’s reimbursed poorly, thus fewer students are attracted to it.
New Guy, you’re making my point with every post. When I see things like Grunt’s statement “Markets. Faster.” I have to laugh because you guys have no concept of the market.
“Hospital-based physicians like ER docs don’t get to choose many of our working conditions, including little things like whether we accept Medicare or not… or whether to have malpractice insurance or not.”
Think about this post. WHY DO YOU HAVE LOBBYING ORGANIZATIONS if not to allow you more power over your working conditions? You can cite me chapter and verse on every bogus “statistic” on tort reform and extol the benefits of myriad legislative proposals on the subject, yet you can point to nothing moving you towards a free market, much less empowering you in your working conditions. What do your lobbyists do for YOU? Not your liability carriers and drug companies, but YOU? Incidentally, your hospital accepts Medicare because it probably can’t survive financially without it. Thus it is subject to EMTALA.
“As for the AMA, they have been losing power for years, as physicians have fled the organization, correctly determining that it doesn’t really serve their needs.”
This may be true, but that’s not how the public sees it. Kind of like you probably think the ABA is a huge force in the daily lives of attorneys. Still, fully 20% of all physicians are members – is there any other physician group even close to that size?
“And the AMA does NOT control medical school enrollment. They have a partial role in accrediting schools (along with the AAMC, which is made up of the schools themselves), but where do you get that they control enrollment? ”
So a group whose members benefit by restricting competition, and a group of medical schools, who aren’t all that interested in adding competitors either control it. I stand corrected! But you do realize this only proves my point though, don’t you? There is no free market to it. Your statement about the cost of developing a medical school sounds like it’s straight from a medical school/AMA lobbyist justifying this. Maybe it IS cost prohibitive, but how would anyone know since if they did build one they have to get with the existing cartel to be allowed to fill the spaces for students!
Either way, are you actually claiming that a group which has at least 50% of the control of how many physicians there are isn’t a pretty damn powerful lobbyist?
Maybe it’s the AMA’s fault there aren’t enough physicians doing primary care, but when you arbitrarily restrict the number overall through medical school admissions, haven’t you lessened the chances regardless?
I actually feel bad for you, even if you don’t believe it. Your profession has limited its options severely in exchange for being money whipped by the government. Maybe that gravy train will continue so at least the tradeoffs will be worth it. If I were you though, I wouldn’t be that confident that it will, particularly when you look at pay in other nations with single payer. You know – those countries whose legal systems you’re always raving about and wanting us to adopt. Of course, if our government can gut trial by jury, taking control of medicine is nothing.
Do you have a reading comprehension problem, Matt?
The AMA is NOT “my lobbying organization.” I want nothing to do with them. I consider myself an individual doc, and I write my legislators. As for EMTALA, that is never going away… too many people are now used to getting something for free. For hospital-based physicians, you’re at the mercy of the hospital, and they absolutely can’t live without Medicare, which is likewise never going away.
So I’ll say it again… the AMA is not “my” lobbying organization.
As for your “the public thinks AMA=physicians, so perception=reality” argument, most people also think attorneys are bottom-feeding scum. You can make that argument if you want…
With regards to accrediting schools, the AMA appoints a half-dozen physician members to a panel (along with the AAMC) to help accredit medical schools (I suspect the ABA has a similar arrangement) There are also non-physician members to that panel… so the AMA doesn’t have majority control. They also don’t control how many students a given school can take… so an accredited school could easily bump up their enrollment to produce more students.
HOWEVER, that’s not enough. Those students need GME (residency) to have a license… and THAT is controlled by CMS. You could increase residency slots (which are govt. funded) and bring in foreign medical grads (being done). You could also increase the clinical capabilities of extenders (being done). The AMA controls none of those things.
About 30 years ago many states opened up new “primary care” focused medical schools, but they couldn’t force students to rank/match primary care residencies. Many students correctly determined that primary care was a lower-paying specialty full of paperwork and long hours, and went with something else. Again… not the AMA. The government controls reimbursement through the price controls instituted by CMS.
Why don’t you set up your own medical school if it’s such a piece of cake, Matt? Unlike setting up a law school, where you only really need a library, a lecture hall, a couple of attorneys, and a mock courtroom, medical schools require a lot of hard-science disciplines to support their education. That’s micro labs, anatomy labs, surgical labs, hospitals, expensive equipment… What you really DON’T want is to make a free-for-all situation where anyone can hang up a shingle and call themselves a “medical school” Not even the ABA allows that, unless you’re arguing that anybody should be able to sit for the bar exam after graduation from “Joe’s VOTECH and unaccredited Law School.”
You really don’t understand this process nearly as well as you think you do.
“he AMA is NOT “my lobbying organization.””
You can say that all you want. And I get that you believe that. But the facts are that they are being relied on in a major way in Washington to make legislation and represent doctors’ interests. You may not like it. Hell, I don’t like it, but it’s a fact.
“As for your “the public thinks AMA=physicians, so perception=reality” argument, most people also think attorneys are bottom-feeding scum. You can make that argument if you want…”
I’m not saying perception=reality. I’m saying that people are looking to and believe that the AMA represents most physicians, and if you want to claim they don’t, you better improve your own lobbying techniques to get the message out.
“so an accredited school could easily bump up their enrollment to produce more students.”
No, they can’t. Because there are a limited number of slots. What’s more, the same entities control accrediting process. If you want to start a medical school today, where would you go first? Probably to get accredited. Who would you go to for that? Your COMPETITORS? Let’s say you pass that hurdle. Now you need students. So can you admit anyone with X GPA and X exam scores, you know something objective? No, you can’t. You have to go to a professional lobbying organization and again, your competitors, to fight for an arbitrary number of openings which you can allot to your school. Only a physician thinks this is ordinary.
“What you really DON’T want is to make a free-for-all situation where anyone can hang up a shingle and call themselves a “medical school” Not even the ABA allows that, unless you’re arguing that anybody should be able to sit for the bar exam after graduation from “Joe’s VOTECH and unaccredited Law School.””
The ABA doesn’t control law school slots. The AMA has a unique power among professional lobbying groups. In some states, you don’t even have to go to an accredited law school – in fact, in California you can take the bar after not going to an accredited law school, but you have to take a “baby Bar” first.
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