Primary care about to collapse

[rainbabies]

[SuzySunshine]

I can second that using my DH as the PERFECT example. I think most women are good about getting annual exams, but they don't usually include full physicals and wellness type stuff. Men, on the other hand, go to the doctor when they are sick.

Typical exchange between me and my DH:
Me: "You should go see a doctor, when was the last time you had a full check-up?"
DH: "I see plenty of doctors every day!"

The fact that his father and both of his uncles were all on choloestrol medicine before they were 40 doesn't seem to phase him!

[Meenah]

I guess this is good for me!!!
Luanne

[Rapunzel]

Yeah, I'm thinking that nurse-practitioners will be encouraged to be used more frequently by those that reimburse (ie insurance and the gov't). Why? It's cheaper to hire an NP than a FP or internist. And, for business saving (and making) money is always the name of the game. NP's are already used a great deal at the peds practices I've taken my kids to in the past.

On a similar note: Radiology is having a serious problem convincing anyone to subspecialize in women's imaging (mammography). Medicaid reimburses very, very low for mammograms and the insurance companies base their reimbursement rates on the Medicaid rates. It's also become very "in" to sue mammogram readers and they have correspondingly astronomical malpractice insurance. So, there is predicted to be a huge shortage of radiologists in women's imaging in the next few years. And, that's one field that cannot be filled by NP's (or other physicians for that matter - it's too specific and requires subspecialty training on top of residency). As the grandchild of a woman who died of breast cancer this sickens me.

[mommax3]

The whole topic of reimbursement just makes me mad. I was pretty naive before now, since DH was in the military, but my eyes have definitely been opened. However, I was not as naive as my sweet MIL, who asked DH before he started his new job, if he had "set his rates" yet. As if he even gets a choice!!!!

DH and his partner are taking medicaid right now, partially because they are just getting started, and partially because they feel like it is the right thing to do. The reimbursements, however, are horrible and if their practice was 100% medicaid, they wouldn't be making enough to cover their costs. In addition, patients on medicaid are more likely to sue, (DH told me about some study that showed this) meaning that by taking care of them, DH gets paid less *and* increases the risk that his malpractice insurance will go up. He really enjoys all of his patients and is not planning to opt out of medicaid....there aren't too many OBs on this side of town that accept it and DH thinks that is wrong, although he understands where it is coming from. But he and his partner are trying to keep their medicaid patient load to a certain percentage of their total practice.

I don't know what the answer to this all is, but DH's time in the military has more than convinced me that we do NOT want the government in charge of America's healthcare. I wouldn't mind seeing some CEOs with private jets, etc. having to pay more taxes in order to fund these initiatives, however!

[PrincessFiona]

It's such a complex issue....Sally..dh and I were also discussing Medicare/medicaid stuff the other day. He was comparing the govt. program to NHS and Canadian care and he basically said that medicare is actually *well-managed*...the problem is that it is underfunded.

Basically, the problem that he has with seeing medicare/medicaid (though he does, of course) is that they pay less for visits/procedures etc than it actually costs to do them. If you walk into an ER and have private insurance, they might bill you $200 for an x-ray, knowing that they have a deal to get $120 in payment. If you have no insurance, you're stuck paying the $200. If you 'pay' with medicare, they might get $25...when the actual cost of paying the radiology tech/nurse/machine is (for example) $50.

So his take on this is that those of us with insurance are paying twice...we pay medicare tax (1.25%) and then we also pay insurance premiums. Those that can least afford it are charged the maximum.

Medical costs would likely go down for the insured and uninsured if we weren't having to pay to make up for the fact that medicare/medicaid don't pay enough to even break even. We'd probably have to raise our medicare contribution though to ~3%.

It's really quite sad, because I am of the mind that basic healthcare needs to be available to everyone regardless of whether they are the CEO of a big pharm company or are a schizophrenic homeless man on the streets.....there should be a better safety net in a country that boasts the 'greatest healthcare system in the world'.

Our prioritites are just out-of-wack. We're willing to put billions into military/war/building bridges in Alaska...but not into the medicare system.

Why is it that in this country is feels like it has increasingly become about "me, me, me" and less about "we the people"?

kris

[Vishenka69]

As far as my HMO is concerned I don't need a physical. Seriously they don't pay for regular check-ups and only cover problems. I'm baffled by the logic that paying to fix a problem is cheaper and better than preventing it in the first place.

[DCJenn]

This is an interesting discussion that is particularly important to my family:

Grandmother #1: fell, broke her ankle and is currently at a rehab hospital. Because her husband lived long enough to retire AND they owned a house that they sold at a significant profit AND she lives in a rent controlled apartment AND my dad took all of her proceeds from all of the above and invested it so that she has an income- she can now afford a very nice "assisted living" facility here in Maryland. It's an age-in-place facility so she'll have the same efficiency apartment as her needs increase. (and Medicare will pay)

Grandmother #2: Fell, didn't break anything but needs to move to a more protected place. Because her husband died at age 45, they didn't own their own home, she's lived on the economy in a non-rent controlled apartment AND she spent any extra money trying to get assistance to my drug-addled uncle- she is on Medicaid and will have to go to a Medicaid funded facility.

Think there's a difference? It's scary how different they are. The differences are not just with what the physicians are reimbursed though- and to be honest, that's the least of the issues. The differences is in how the direct care staff are paid, whether the nurses are LVNs or RNs, whether the med techs are making more than minimum wage (all of $6.15 in MD), what kinds of activities (if any) are available, where they eat, what kinds of foods are prepared, etc.

The bottom line is that my 'rich' grandmother gets to live in a pretty nice place and my 'poor' grandmother gets to live in the kind of place that I routinely surveyed and cited for bajillions of horrible things. Crappy things happen to good people and the tailspin that it can cause means there are a whole lot of good people who have no healthcare. (or homes or jobs for that matter)

The Medicaid system is a ginormous failure, as is Homeland Security and the IRS (nice how they withheld the refunds of 1000s of those who had the least amount of income, huh?). However, I believe that if the government doesn't provide these services, no one else will. Who will fund the group home for the person with mental retardation with no family? Provide treatment for addicts? (and no one can argue that it costs less to treat than to incarcerate) Who will pay for the elderly person with no family? It's all well and good to assume that people have support systems but not everyone does.

What about abused kids? and homeless people?

It boggles the mind but it's the most vulnerable members of our population who are getting crap for medical care, if any at all.

I think it is important to remember the differences between Medicare and Medicaid because they do operate differently.

I agree that M'caid is a ginormous mess (I have less ill-will towards the SCHIP). M'care has very low administrative expenses, partly because everyone is mostly on the same plan. I think a huge problem is all the different insurance companies with different plans that have different regulations (state to state differences versus federally regulated). A ton of money is wasted on administration.

However, as someone who has suffered through calls with M'care on behalf of my in-laws, I can attest to the messy bureaucracy of it. It just about makes me pull my hair out to talk to them. I absolutely can't imagine what it must be like for an 80 year to call them, deal with the f'ing phone tree, and try to ask a question or settle a claim. It is maddening. I've also heard that the reimbursement schedules can be weird.

As to the primary care, I know that our pediatrician in Denver kept his office afloat w/ NPs. DH was the primary care poster boy and he bailed, thank goodness.

Sally....Has he set his rates yet? Wow! I'm sure that is what most people think, how else would they know. But. :! [/b]

[mommax3]

Sally....Has he set his rates yet? Wow! I'm sure that is what most people think, how else would they know. But.

I KNOW!!!!! And my MIL is an educated and fairly sophisticated woman who is taking care of two elderly ladies (her mother and MIL) and is dealing with drs. all the time as a result.....not to mention that my FIL is a veterinarian, although he is in administration. Still, if she doesn't get it, how many others don't get it either?

Sally

[spotty_dog]

not to mention that my FIL is a veterinarian

I think that explains it right there. To judge from the clinic I worked in and the vet clinic management magazines I used to read and the veterinary practice management textbook I studied choosing a rate scale is one of the defining parts of setting up a veterinary practice.

[DCJenn]

The difference between Medicaid and Medicare is can be boiled down to Old vs. Poor/Disabled. The reimbursement rates are distinct enough on the provider side but on the user side, the services are similar enough to be lumped together. and really the problem is that there's not enough money to fund any of it adequately which gets back to the sucky reimbursement rates.

(and actually there are even more ways to circumvent the insurance programs for services to elderly and disabled people that the states use, such as Medicaid Waiver and ICF/MR facilities)

But while I'm at it, let me also include the entire VA system...nightmarish program that it is. (can't tell you the numbers of stories of the problems people have getting into THAT totally overworked and underfunded medical system.)

and how about this fabulous Medicare Part D? Yeah, that's worked out really well- as my 'poor' grandmother found out when they couldn't fill her prescriptions...

It's all a nightmare- no debate there!

Jenn

and Vishenka's point about preventative care not being covered? how stupid is that? Medicaid will pay for emergency dental but not preventative dental. Guess what you need with no dental care? It makes NO SENSE.

As far as my HMO is concerned I don't need a physical. Seriously they don't pay for regular check-ups and only cover problems. I'm baffled by the logic that paying to fix a problem is cheaper and better than preventing it in the first place.

Look at how many insurance companies won't pay for birth control, but of course they cover the birth!

[DCJenn]

Or cover Viagra but not birth control...

J.

[PrincessFiona]

Or cover Viagra but not birth control...

J.

Well, you know, Jenn...not being able to get an erection is like...a medical emergency.

kris