You Have No One To Blame But Yourself

On July 1st, for the second time in less than a year,  Congress held a vote to "save" physician payment.  To fend off a Congressional mandated cut as established by the unsustainable sustainable growth rate formula.  That cut of 10.6%, along with a conservative guesstimated overhead expense of 50% of revenue, along with 2.5% per year rising overhead expenses, along with inflationary pressures of the CPI equate to an immediate 25% drop in take home pay for every single physician who operates in a 100% Medicare practice.  Now, some may say that no physician is 100% Medicare.  And you are right.  Because if they were, they would not be able to financially sustain their practice (at least primary care comprehensive care docs).  I walked you through the numbers in my post about screwing over granny. 

Here's my position.  It's time to let the cuts stand.  Congress should not reverse the 10.6% cuts that began in July 1st 2008.  And here's why:  The financial mess we are in now is entirely a result of third party interference of the doctor-patient relationship.  

The party in control of 2.2 trillion dollars worth of health care money being spent every year are physicians.  The financial cascade of capitalistic profit from every corner of the health care universe begins with a physician order.   The comprehensive care physician-patient encounter is but a very small portion of the total health care dollar pot.  When that physician writes an order for a walker, or an oxygen tank, or a statin or an outpatient ultrasound, or a hospital admission, that order starts the ball rolling on a cascade of profit for every downstream vendor that relies on that magic pen of the physician.   

The physician is in complete control, and yet, along the way they have been led to believe that they are being controlled by the patient, or better yet, the patient's insurance.  I blame comprehensive care physicians for allowing themselves to become the step child of the medical profession.  For allowing themselves to sink so low, to think so little of themselves that they would allow themselves to practice their profession for a price less than that of a nurse practitioner of anesthesia.  The docs are to blame.  No one else.  Why?  Because they are the ones signing the insurance contracts.  They are the ones accepting their own demise.  I blame nobody but the docs.  

The government does not care about your health.  They care about your vote.  They care about what is best to keep themselves in office.  The political nature of the Medicare system prevents the right change from being instituted.  The goal is less cost.  Not better health.  The fact that my Congressman thought a medical home was the same as a home visit by a doctor to their house is evidence enough to me of the lack of brain power making our laws.  Lawyers don't practice medicine.  Doctors do.  And we can all thank the Lord for that.  Unfortunately,  the lawyers have their mitts in everything that is medicine.  And right now us doctors have allowed a bunch of lawyers to tell us how we can take care of patients.  I blame the doctors for letting it happen.

There are those that say we must accept Medicare as a duty to our oath.  That the poor Medicare patients with no money have no where to turn to but us.  That is a pure and utter lie.  As a doctor, my duty is to my patient.  My duty is not save the world with free and subsidized health care.  If I want to establish a relationship with a patient on equal terms where both parties are satisfied with the terms of agreement,  that is the extent of my duty as a physician.  My ability  to provide subsidized care to those less fortunate is an option that all physicians should consider.  However, in the current payment system,  all patients are considered charity patients, and all comprehensive care physicians accepting Medicare should pat themselves on the back for their generosity and charity they are providing for the system.

But your generosity will only take you so far.  At some point, you will have to save yourself in order to save granny.  

The current laws state that should a physician decide to forgo Medicare,  they are not allowed to order any test (that means labs and xrays or durable goods) that could be paid for under the patient's Medicare benefit.  A wonderful anticompetitive clause built right into the system.  Medicare has hogtied both the physician and the patient.  If a patient wishes to see a comprehensive care physician that takes no insurance,  that physician cannot order any tests to be paid for under the patient's insurance.  That means no CBC for an episode of syncope.  That means no abdominal ultrasound for right upper quadrant abdominal pain.  It is an anti competitive law that prevents doctors from exiting the system while still allowing them to care for Medicare age patients on terms that both patient and doctor agree to.  It's the equivalent of asking an architect to practice without a pen,  a construction worker to practice without a hammer.  If I can't order lab or xray,  I simply can't provide appropriate care to my Medicare patient, all the time.  And the lawyers who designed Medicare know that.  

This single rule has hogtied the comprehensive care physician into an all or none phenomenon.  They can't go cash only for  the Medicare patient because the actual expensive part of care (procedures/xrays/labs/durable equipment) all require your physician to accept Medicare to order anything that should be paid for by Medicare.   Your government is screwing granny more than you ever knew.

I blame physicians for allowing the profession to dumb itself down.  To turn itself into volume mills where the only thing that sustains itself is higher and higher volume in the setting of stagnant and declining revenue and ever increasing practice expenses.   By hiring extenders that do nothing more than add patient volume to the schedule while providing less educated and less sophisticated care.  The extender movement is the direct result of the economics of Medicare.  It drives volume.  It doesn't drive health care.  And that extra volume simply adds more expense to the Medicare system.  With adequate payment,  extenders would be unnecessary.  They are but a profit arm for all that use them.  

Comprehensive care physicians provide a service.  They are a knowledge bank of information that can see the big picture.  After 12,000 plus hours of residency and 4 years of 100 hours a week of learning, they are the special breed of doctors who can care for the whole patient.  They can't be replaced by a computer or an extender.  They can't be replaced by a specialist (who has no desire to do this type of work).   They have relied on insurance to pay their bills.  Now that insurance has let them down,  it's time that they take their service to those who value what they have to offer.  

Physicians are notoriously competitive.  That's the result of the type of competition it takes to get into medical school, to learn, to excel.  It is not the field for slackers.  For those who just skate by.  Practicing medicine takes talent by the cream of the crop students.  Students who will jump ship for a high powered legal profession, or wall street shindig at the drop of a hat.  High income potential is a top priority for any highly intelligent hard working studious student looking to enter a career.  Comprehensive care has left that field of options.  

We are at a cross roads.  For every year that payment rates fail to increase,  not just survive a cut,  but fail to increase,  the expense of running the business eats away at take home pay.  That means more volume.  That means more extenders.  At some point, between all those that quit and retire,  the question from those who remain will have to be,  how much more of this can I take?  

That competitiveness that drives physicians is one major reason they have not jumped ship from the obviously destructive forces of the Medicare payment formula.  Most physicians fear that their patient will simply go to another doctor's office and they will lose that income forever. I have two comments on that.  

1. You are not alone.  Your competition struggles just as much as you do
2. It's time you stop thinking about others and start thinking about yourself.

It doesn't matter if your competition will take your patient.  Your duty is to yourself, not your competition.  If your competition takes your patient,  so what.  Your decision to drop out of insurance is a decision based on your practice expenses, not on your competition.  They may accept less take home pay.   They may accept 14 hour days at the office.  They may have side businesses that are more profitable.  Your decision to exit Medicare or any other insurance has to be made on your own business model and not based on your fear of your neighbor's success or "stealing"  your business.  Remember,  if you are struggling with Medicare,  more than likely, your neighbors are too.  In fact,  your decision to drop out, may in fact be the catalyst necessary for others, who feel just like you, to drop out as well.  

Some argue that the patient will just skip the primary care doc and go straight to the specialist.  So what I say.  That's not something you need to worry yourself with.  If you sign the contract, you have nobody to blame but yourself.  You are allowing others to look at you with mediocrity.  If you are unhappy with the payment rates of United  or Aetna, or Medicare,  you have no one to blame but yourself.  Being worried that another office will take away your business is the reason you are in this position to begin with.  Your competition, your fear of losing out,  your failure to value yourself has lead you in a race to the bottom.  You have no one to blame but yourself.  

Some argue that patients will simply go to hospital owned practices who would never drop Medicare.  I say so what.  The doctors working for the hospitals have to show their value as well.  If Medicare rates drop 10%, that means hospitals are getting 10% less revenue from their docs.  That means the docs must produce 10% more (which they can't, and is a likely reason they sold their private practice),  or they will have to accept a 10% pay cut or the hospital will have to eat that 10% charge (which would never happen).  

So comprehensive care.  Blame yourselves.  You signed the contracts.  You created the volume mills.  You are pretty alone in this problem (minus a few general surgeons).  There are plenty of cardiologists and gastroenterologists being spun out of our medical schools with their high procedural/profit streams.  You are on your own in this battle you have been fighting  to the bottom for the last 15 years.  Blame yourselves.  

Breaking the cycle to the bottom will demand a change  from the bottom up.  You will have to force change onto the system,  one doctor at a time.  You will have to stop caring about how other practices will respond.  Your fear of being pushed out of the market by your competitors is relevant only in so far as you accept your current demise and race to the bottom.   Once out of the insurance business, you can let the others complete the race to the bottom.  But, my suspicion is that your impetus to action will drive others to respond as well.  And if they don't,  so what.  You can only control your own practice model. 

And if you choose not to change, you have no one to blame but yourself.