The 5% Are Killing Us All

Internist Dr Centor over at DB's Medical Rants sums it up nicely:

1. Because we manage chronic disease better than in the past, we have more complex older patients living with multiple diseases. These patients need physicians (mostly internists) to manage their conditions in the outpatient setting.
2. We have a shortage of outpatient adult physicians. The Massachusetts experiment makes this shortage very obvious. Having insurance is not enough, you must have a physician to see once you get insurance.
3. We have a large and growing demand for hospitalists. Our graduates are preferentially choosing hospital medicine for intellectual, lifestyle and financial reasons. Despite the positives, we are not producing enough hospitalists. Moreover, many hospitalists leave hospital medicine after a few years for subspecialty training Hospital medicine is expanding as almost every other specialty and subspecialty willingly takes advantage of hospitalists to end their hospital practice, switching to a consulting practice.
4. The preference to choose hospital medicine has markedly decreased the supply of new outpatient internists. A significant percentage of outpatient physicians have left (or will leave) practice and joined hospitalist groups.
5. Several subspecialties probably need greater numbers, especially geriatrics, nephrology, cardiology and critical care (note that many hospitalists are providing critical care.)

yes, yes, yes, yes and YES

I learned last week that my city will loose yet another internist. I don't have a clue where he's going or what he's going to do. A couple years ago we lost one to an insurance company. A 9-5 job, no weekends. No lawsuits. And every time we lose an internist, no one is left to fill the void. I also learned that zero graduating internal medicine residents from my program will be planning on practicing outpatient clinical medicine.

Zero. Zip. Nadda. A giant goose egg. 1/2 are doing hospitalist medicine. The other half are doing fellowships.

So the question is. How long can this last? It's been going on for years. With every cut or failure to increase funding for comprehensive care; with every 10% rise in tuition. With every 15% rise in health insurance premiums for your office staff. With every increase in preauthorizations from the third party interference. With every demanding, self indulged, entitled patient that can't take no for an answer. With every ambulance chasing lawyer waiting to pounce on every possible permutation of a bad outcome. With every manipulation of the economic free market, we have landed ourselves exactly where anyone without dementia could have predicted.

If you want more internists, you have to pay them more. A lot more. And not just a few thousand dollars. Increasing residency slots for internal medicine won't increase outpatient internists. It will increase the number of hospitalists and medical specialists.

It's about money. It's about lifestyle. It's about respect. The current mafia known as the RUC has killed out patient comprehensive care. If we want to fix internal medicine or family practice for that matter, we must exit the skewed payment model known as RVU/SGR. If you want internal medicine to be a center point of patient access, you will have to make it fun again. Nobody who spends their entire high school, college and medical school career working their ass off will become the lowest paid, under appreciated, but most cost effective physicians. The docs we need the most of are rewarded the least. The docs who have the single greatest ability to pull back the unrelenting reigns of health care spending are leaving in droves.

And we all sit back and wonder what to do. The morons at the Medicare National Bank year after year after year continue to experiment with one demonstration project after another. It amazes me. When all shit hit the fan, our Congress was able to spend $700 billion dollars in less than two friggen weeks. But it's taken an entire decade of warnings to Congress on the gravity of the situation and nobody wants to listen.

Imagine for a moment if Henry Paulson stood up tomorrow and said, "Today is an emergency of catastrophic proportions. Medicare is bankrupt and we must act today to save America from a catastrophic future collapse. I am asking for authorization to spend up to 30 trillion dollars to shore up the program's solvency."

We are sitting her in 2008, talking about never events that may amount to several million dollars a year in savings. We are talking about recovery audits that may net a billion here and there. We are talking cutting payments to providers and insurance companies that amount to several 10's of billions of dollars. It's all pocket change. Any savings you see in one year will be eaten up by the double digit health care inflation we have seen for the last 40 years.

In America we want everything. We are selfish. And we want somebody else to pay for it. I'm here to tell ya, we can't afford it. We have been unable to afford it for years. And that basic concept is accelerating every year we sit on our asses and do another demonstration project to prove we can save a couple million dollars here and there. The Medicare crises that nobody wants to deal with is like this. Imagine the current foreclosure and sub prime mess being the result of the current housing market of South Dakota.

Now let me put the Medicare disaster in perspective. The current global economic collapse is to a the foreclosures of South Dakota farm houses as Medicare is to the California, Nevada, Arizona and Florida foreclosures combined. The Medicare disaster will make the current collapse look like a children's book.

I believe we are heading toward the bottom of the K-Wave, a 60-70 year cycle of economic cleansing, the bottom of which nobody can predict. And no matter how much money the government throws at the problem the cleansing of the ponzi scheme will play itself out.

As for Medicare? We know that 5% of the population spends 50% of our health care dollars. That five percent is killing us all. They are a risk to the financial security of our nation, and ultimately our national security. We cannot continue to sustain our health care funding on the backs of a fee for service enterprise for these 5% of the consumers. They must be pulled out of the traditional payment model and thrown into something completely unorthodox. A radical change for a collapsing house of cards known as the MNB.

I believe that the top 5% spending 1/2 our money ( both Medicare and private insurance) must exit the fee for service model that has made health care insurance too expensive. The 5% that has turned insurance into currency. That 5% driving health care expenditures must be reigned in. And that will require extraordinary measures. How you ask? There is no way any meaningful reform will ever come as long as those 5% are spending all our money. And the drug companies, hospitals, providers and device manufacturers continue to rake in over a trillion dollars a year in management of their various disease states. The fractured nature of their care, spread among multiple specialists is ripe with complications, excess interventions, irrational expectations and impractical solutions. These 5% need to be brought back to economic reality. And that will require a massive coordinated effort.

I believe that should be done by mandating that they receive their care within a new group care model. If you become a top 5% spender, public or private, you are mandated to enter care under a federally funded group care model. You have no choice, except to pay out of your own pocket. These are drastic times for drastic measures. You are not insurable and your expensive health care consumption is a national security issue. Your 48 year old or your 78 year old with COPD, CAD, Stroke, Afib, stage IV CKD, PAD, that spends $100,000 a year in fragmented medical care, procedures, office visits and hospitalizations, will now be required to receive their care by meeting with salaried groups of general practitioners, specialists, pharmacists, nurses, therapists and social workers in large coordinated group health care encounters. This optional program is available to all physicians. They may choose to work full time in this salaried model, or they may choose to work part time and carry on their own fee for service practice. It's optional, and as such, the salary is a mutual agreement between Uncle Sam and provider. Therefore, no animosity. As a benefit of the program, a percentage of any savings generated by this coordinated care model will be paid back to both the providers AND the patient AND hospital for decreasing costs of their care. It gives skin in the game for both patients AND providers AND hospitals.

One of the biggest struggles in my daily practice is the lack of communication in the delivery of health care. When you have 7 doctors managing one patient and nobody talks to each other, multiple medication errors, interactions, organ failures, hospitalizations and complications occur because of no one talks to each other. I believe strongly that forcing the expensive consumers of our private and public coffers into coordinated salaried care models, where the incentive to do more is removed, is necessary to reign in the cost factor of our out of control spending. To make health care cheaper for everyone by spending less money on ineffective and uncoordinated care. To keep folks out of the hospital. To keep them out of the procedure labs. Out of the ORs.

Every morning my group meets with a pharmacist and social worker and we discuss all our patients for possible discharge plans and medication interactions or adjustments. We save hundreds of thousands of dollars a year in pharmacy costs simply by having daily access to a pharmacist's expertise. We expedite discharges by notifying our intent for discharge, to coordinate transfers earlier in the day to decrease length of stay. The cost savings associated with communication is astounding. Communication drives the efficiency. Not ordering a hemaglobin A1C that the current PQRI program wants us to do. . I also see it on the floors when two doctors discuss the specific nature of patient care. Having immediate access to all specialists involved in patient care can save hundreds of billions of dollars in complications and unnecessary procedures and interventions. I am a firm believer in group collaboration  think and communication as it relates to saving money in health care. It is a powerful force underutilized in our current delivery model. And impossible in the current fee for service.

And internists should be leading the way with these coordinated group care models. We need hundreds of thousands of generalists able to understand the big picture when specialists from every field focus so tightly on their area of expertise. We need Dr Centor to be the jury foreman for the coordinated care model. This is not a medical home. This is a Mall of America. A mandated one stop shop for all your coordinated efforts to reign in the costs of these cost centers. To create less harm. To reduce complications. To increase quality of life. I am not talking about ration. This is not rationing. This is quality care through direct coordination. Pay the physicians to be doctors, not revenue generators. And pay them a bonus for saving money through quality. And pay the patient for participating in their health care. It's a different approach to PQRI. Ultimately, no matter how you try and package it, the government views quality as decreasing costs. So leave it up to the physicians and patient how that will be done. And if they succeed, they will reap the benefits of their efforts.

We need internists badly to drive group coordinated care. We need to get those 5% driving all our expenses out of the current fee for service system. To make insurance affordable again for the 50% who only spend 3% of all health care dollars. We need to pay doctors well who volunteer for this service, to help save our Medicare and ultimately our national security. I love the challenge of complicated medical patients. I love speaking with other physicians caring for my complicated patients. I love the coordination involved and seeing the success in our fruits. I would be honored to provide service to complicated medical patients in a federally salaried coordinated care model such as this. It's basically what I do in the hospital in a supercharged format. I am constantly talking to physicians all day long about the care of my patient. To have them all present simultaneously would be a major step forward in decreasing costs associated with the sickest and most expense of our patients. The 5% are killing us all. A slow and steady death. Are we going to sit back and allow it to happen, or are we going to do something about it.?