Another factor in the Health Care Reform Debate

[JaneDoe]

http://www.newsweek.com/id/234218/page/1

While the cost of medical education is mentioned in this article, it is more of a passing reference than an actual point.

In our local paper recently was an article about a local family practice doc. who was leaving his practice to go work for Kaiser. He explained that with all of the insurance red-tape and the low reimbursement rate, his practice is not financially viable. He chose to go work for Kaiser so he can just practice medicine and leave the paperwork to someone else. The article's focus was on the severe shortage of GPs in our area and why we are losing the GPs and failing to recruit new ones.

In response to this article, a woman writes a letter to the editor complaining about the "greedy doctors". She said she has called "all of the family practice doctors in the area" to see if anyone will take her as a new patient. She explained that she has medicare insurance and none of the doctors are willing to take new medicare patients. Her reasoning seemed to be that if only the "greedy doctors" would agree to see more medicare patients health care problems would be solved.

Whatever. I paid the guy from Sears about triple the reimbursement rate for a medicare visit to a GP last week just to show up at my house to fix the washing machine.

I think the cost of medical education has to be addressed in health care reform. Until something is done about that, we will continue to have a shortage of GPs. Whatever "health care reform" might be pushed through Congress will be useless until this very issue is addressed. Coverage can be expanded, but it is meaningless until you get more GPs to see patients who would be newly covered as part of the reform. Sadly, this just doesn't seem to be on lawmakers' agenda. They want a quick fix, when this issue requires a much more complex fix than is being proposed.

[PrincessFiona]

I have brought this point up a few times as well. I don't see how health reform can come in, doctors can be paid less, but the cost of an education and low pay during residency and fellowship/hours work and educational status can continue.

In the UK, for example, when dh worked as a Senior House Officer, he earned much more money percentage wise than he ever did hear as a resident. Call in Germany is compensated extra for residents. Here, you are slave labor and you take your spankings because it will be "worth it some day". What happens when it isn't? If the money is even tighter, the loans are higher and the interest is growing and the pressure and high stakes of medicine stay the same....will the best and brightest still go into medicine?

ETA: This is sort of being addressed by the hiring of mid-levels who get paid less for the same job.

Here, PA's work as hospitalists and in every other field. Supervision basically consists of asking if they have a question...otherwise they work independently. In outlying communities, some PAs are the only medical provider around.

Is that right? I don't know. Some studies in Family Practice/IM have compared NP's/PA's and docs in the treatment of certain illnesses ... and have shown outcomes to be the same...but NP's actually have the best results for management of chronic illnesses like diabetes. Does that say that the rigors of med school/residency are overkill? Does it say that many illnesses are self-limiting and treatments are overkill? I have no idea...but I see mid-level providers as ultimately being what brings down costs...and fewer people will probably pick medical school...

[DCJenn]

We manage our sobering unit w/ a PA, a couple EMTS and the nurses from the detox unit are back-up. (although the nurses can't do IVs and the EMTS can) We tried to staff it with psychiatry residents and honestly, they're more trouble than they're worth. The detox unit has a MD medical director, and RN supervisor and the rest of the nursing staff are LVNs. When I go to the Family Medcine clinic at the Army base, especially if it's an acute appointment, I'm going to see a NP 9/10 times.

We have discovered that the staff we have are actually better at providing the care than the MDs. a LOT better. We have protocols that were written by the MD but you don't need 4 years of medical school to take a pulse and give someone meds because they're cranky because they're detoxing. You DO need a MD when they have a seizure from alcohol detox and that's when we call EMS and have them taken to the ER.

I think you raise a valid point- have docs specialized themselves out of the general medicine world? Out of all of the peds residents of my husband's class, five are general pediatricians. The rest (10) have all specialized. It used to be that your general pediatrician took care of the allergies, the seizures, the earaches, the stomach pain.

and back to the original point, I heard a really interesting blub on NPR recently about how Lyndon Johnson at the time of the Medicare rule implementation decided to go w/ the physician lobby mandate that the physicians be allowed to determine the fees for fee for service delivery. He said they knew two years in that it was a colossol mistake and health care costs had already started to skyrocket (and this was 1967!) and they tried to go back and get Congress to let them take out that part of the legislation and they were told absolutely not by the politicians. So, the docs have to a certain degree created this monster themselves. Of course people would rather pay the NP or the PA - they cost less. and truly, in many cases their services aren't that much different. (except that NP and/or PA is likely better rested and will likely spend more time with you.)

[Sheherezade]

I heard that same piece, Jenn. I think it was from Planet Money and played on Morning Edition. I was also stunned that they said that before Medicare the majority of elder medical care was given away from free or written off by medical practices -- so the doctors actually liked Medicare once it came in because they started getting some income (through government payment) from patients that were previously total losses. Of course, this would have been before we increased life expectancy so dramatically. Medical care for the elderly can now go on for decades and at great costs. I wonder if this would have happened if they'd still been primarily treated on a charity system. I know that when I was a kid, my whole family was routinely comped by other medical practices -- and my father comped the service to their families as well. He just ate the costs and didn't charge. That stopped happening in the 80s when insurance and insurance contracts seem to take over the business of private practices. I wonder if it was cheaper before!

Caveat: Planet Money is always anti doctor. I've heard several shows on health costs and felt they don't really have a handle on the practice of medicine. They try...but they are off. So, take the report in that context.

[PrincessFiona]

Re: Another factor in the Health Care Reform Debate

On the fly.

I wonder how patient and family expectations have driven this too though. My mom is an NP doing geriatric care. Family members demand her time, demand all treatment and life-prolonging measures and she regularly is forced into a metaphorical corner.

It's easy to just blame docs, but people also want MRI test for back pain, antibiotics for sniffles and can be ruthless about getting these things.
Care for the elderly wasn't always reimbursed, but life expectancy was much lower and we had less technology.
We are moving back to the time of no reimbursement but now the elderly will want their ICU stays, PET scans and expensive cocktails of drugs. How do we comp that or .... Do we? Who pays in the end?


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[Sheherezade]

We are moving back to the time of no reimbursement but now the elderly will want their ICU stays, PET scans and expensive cocktails of drugs. How do we comp that or .... Do we? Who pays in the end?

Agreed. I think this is the conversation that no one wants to have. It is a "third rail" right now. When it was broached in the health care summit by the Democrats, it was swatted away by the Republicans because they KNOW it's a loser. They are the ones that jumped on the "Death Panels" idea this summer. I suppose that they feel that the government should have no say in what type of care you choose or receive -- and I'd be fine with that IF we hadn't already designed a system in which the mythical "grandma" was almost always covered by the government via Medicare. If Medicare spending spins out of control, the only way to make cuts will be to cut services offered. Obviously, doctors bound by the Hypocratic oath are not going to recommend reduced treatment based on costs/payments. Grandma isn't likely to say "Don't bother". So, who will? Or do we just pay for everything? And if we do maintain Medicare as a government program then wouldn't we benefit from pulling in healthy younger taxpayers to help pay for the costs of care at the end of life (like traditional insurance)?

[PrincessFiona]

The money just isn't there even if we pool in young, healthy people. ...and do we trust our govt to run this program? Look at how they cowtow to industry like big pharmacy and then squeeze docs for example.

There is no industrialezed nation with govt care that does not have to engage in what we would consider rationing of care. The difference is that in Europe (for example) people accept the limitations and restrictions.

For example, at the hospital Thomas worked at when he was on oncology, lifestyle issues were also a big factor in care. If you smoked, you would nit get chemotherapy for breast cancer. Not until you could show you quit.

They were hard core about personal responsibility in disease prevention.

Beyond that, with reduced money for the elderly, no heroics are undertaken. Pneumonia is still the old man's friend in European nursing homes.

Also, how do we address that the current systems in the uk and Germany are unsustainable and the programs are in major financial trouble?


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