Another Doctor Ponders Group Exams Under ObamaCare
If Medicare mandates “Preventive Annual Health Evaluation with no copay,” it means many more primary care doctors will have to choose between accepting very poor payment ($179.29 in Santa Ana California), joining the growing number of “retainer or concierge” practices, providing care in a manner that is consistent with the payment provided (a very, very brief exam, or having a PA, EMT or MA do the exam), opting out of Medicare or choosing a different line of work. A waiter at a local restaurant informed me that he earns over $150,000 annually working 4 days a week.
Thinking creatively brings my own personal “group exam” to mind: As recruits in the US Navy, 80 of us lined up in a large room, bent over and a doctor favored each and every one of us, in the most efficient manner possible (no change of glove), with a DRE.
Since this may be the wave of the future and an option of choice for some doctors, this may be a good time to invest in companies that renovate medical offices — removing those unnecessary walls between exam rooms to facilitate those group preventive health care exams. Being sensitive to patient modesty and privacy, the thoughtful physician may insist on blindfolding the patients.
Thinking again about the Senate bill on health care reform, for me this is déjà vu — I am bending over again and the government is going to give me the new and improved DRE — specially designed for the primary care physician.
Very funny. Also, very sad.
We are all going to be bending over.
I don’t know what your costs are. I do know that very few visits to my doctor involved more then 10 or 15 minutes of my physicians time. If you’re getting 180 an office visit, you’ll can easily gross 800 an hour. For a 40 hour week, you’ll gross over 30,000/week. That may not be investment banker pay, but if you think you’ll do better as a waiter, hang up your shingle and start waiting tables.
artk, he’s not talking about a brief meeting. He’s talking about a physical.
I schedule 90 minutes for the complete evaluation of a Medicare patient new to my practice. Medicare patients are, by definition, older or disabled. They usually have multiple medical problems, take multiple medications, are often accompanied by a family member who is supportive and involved in the patient’s care. Their contribution may be quite valuable and it also adds to the time necessary for evaluation of the patient.
At the end of my 90+ minutes with the patient and possible relative or caregiver, I may have to review prior records, order tests, write letters to physicians whose consultation I am requesting.
The overhead of primary care physicians, the physicians who will be providing the preventive care evaluation, varies between 53% and 59.7% (see my article in the New England Journal of Medicine, http://content.nejm.org/cgi/content/full/NEJMopv0909479?resourcetype=HWCIT
for references).
In my practice the average complete preventive evaluation of a new Medicare patient takes me over 2 hours, (yes two hours).
If my overhead was only 55% of gross, I would earn $40/ hour. Do you think that is fair?
So, some patients take 90 minutes, some 10. When I travel I know that the passenger in next to me may have payed 1/3 of what I paid or 3 times what I paid. That’s called price discrimination, every business has to deal with it and medicine has to learn to deal with it. Most of your overhead is fixed cost anyway. How much could you reduce that overhead if you only had the requirements on one insurance company to deal with. My father was a sole practitioner in internal medicine with all the excess overhead that goes along with that. From what I understand, from a patient care and cost basis, medium sized multispeciality groups do a much better job anyway.
The only “insurance company” that I deal with is the government, I do not have any contracts with any insurance companies or health plans. My overhead is my rent, janitorial service, office staff salaries (I pay them a decent wage, pay for their health and dental insurance, retirement plan, uniform allowance and other benefits), malpractice insurance, office premises liability insurance, a long list of taxes and other assessments, payroll service fees, accountant’s fees, electricity, telephone, office supplies, computers and their software, internet access, hospital staff membership fees, county, state and national medical association membership fees, 2 specialty society (American College of Physicians and American Academy of Hospice and Palliative Medicine) dues, publications, attendance at medical education meetings; a long list of expenses and I am probably forgetting some of the expenses.
You are correct, some doctors may take 10 minutes with a patient. If you mean that they provide a comprehensive preventive care evaluation for a Medicare patient in 10 minutes, more power to them. I would be surprised if they could do what should be done in that time, or much more time.
Regarding the medium sized multispecialty group, I prefer, and my patients have been willing to pay the fees that I charge for my mode of practice which is solo private practice, fees that are certainly higher than the usual multispecialty group. My clientele is largely professionals; physicians and their families, nurses, stockbrokers, bankers, attorneys, judges, corporation executives but it also includes truck drivers, clerical workers in health care, teachers and, well paid waiters.
Currently all my patients have the option of paying me for the amount of time that we mutually agree is appropriate for their evaluation.
The proposed Preventive Evaluation With No Copay embodied in the Senate bill will take away that freedom. Welcome to your 10 minute Preventive Care Evaluation. Perhaps Senator Reid will opt for that very efficient exam.
No insurance companies? Never? Your patients write checks when they need an MRI or does your admin fight with the insurance company for a preauthorization. The same goes for hospitalization. You never get called by a pharmacist because their drug plan has a different idea of the correct prescription then you do?
No contracts with any insurance company. The radiologist usually deals with the authorization for the MRI and my patients are rarely hospitalized (because I do not do 10 minute physicals and because they understand why they should not smoke and why they should take their statin, Byetta, ARB etc, etc). When they are hospitalized the hospital fights with the insurance company. I do get called by pharmacists. If the patient will do well on a different drug within the same class of drug I usually agree with the pharmacist if it saves the patient money. If the patient will not do as well with the pharmacist’s recommendation I do not agree. There are instances when the patient will be safer or more comfortable (better control of pain or other symptom) if they ppay for the better drug. That is up to the patient.
Biggest beneficiaries of US Medical system are doctors, insurance and drug companies, malpractice
lawyers. Patients enjoy least benefits. Most doctors dont spend more than 15 min with the patients. Most of the notes is preprinted from previous visits or EMR systems. Physicians stoped doing good clinical exams and nutrition counciling. I do not understand why a doctor needs 150 dollors for the physical exam. US medical system is most expensive and least efficient. It is a money making and profit driven system.
I agree, you clearly do not understand.
This has been a good exchange. I especially want to thank Dr. Sterling for explaining as much as he did.
Dr.Sterling is one of the most respected internists in the area.I know of no other profession where experienced people get paid less on a per hour basis.Looks at senior attorneys (usually 500-1000 per hour),basketball players and golfers.Great article.
I agree with the sentiments expressed by Dr. Sterling.
artk’s comment about price discrimination reveals a lack of understanding of the effects of the “Health Reform” bill. Insurance companies will no longer be able to practice price discrimination. All comers will be charged a single “community rate” and people with chronic diseases will be charged the same as people with no health problems.Physicians are not allowed to practice price discrimination which is one reason the uninsured get shafted.
I only know what I’ve heard: Dr. Sterling is the best of the best at Internal Medicine and Pain Management in Orange County. that’s why I am switching over to him. Better care on the front end (for more money, but getting more time and more careful analysis) means less cost overall to the patient AND to the health care system, including the taxpayer.