Who cares?
An article in the New York Times on April 26th ("Shortage of Doctors an Obstacle to Obama Goals") was full of fascinating quotes from the best and brightest of our solons. Taken as a whole, and assuming their mouths bear even a tangential relationship to their minds, it verifies my April 23rd comment that family practice ought to be in the catbird seat when it comes to the negotiating table.
If you don't have time to read the whole thing in the New York Times, here's a sampler:
We’re not producing enough primary care physicians. The costs of medical education are so high that people feel that they’ve got to specialize. (President Obama)
The primary care physician workforce shortage is reaching crisis proportions. (Sen. Orrin Hatch, R-Utah)
Primary care physicians are grossly underpaid compared with many specialists. (Sen. Max Baucus, D-Montana)
Maybe they're just posturing, which would be habitual. Or maybe it really is dawning on them that there isn't enough primary care capacity in the the country to do what the president wants to do. And this would be the fault of ... whom?
Well, the Relative Value Scale Update Commission (RUC), for starters – an AMA goon squad dominated by procedurists, which calls the shots with the federal Center for Medicare & Medicaid Services, which is wholly responsible for the increasing spread between primary care and specialist incomes. The Times article says the Medicare Payment Advisory Commission, a congressional advisory committee, has recommended a 10 percent increase in primary care payment at the expense of the specialists.
The specialists beg to differ.
Now the food-fight begins. And it's about time. This one could be fought in public, rather than behind closed doors in a mahogany-paneled conference room. This is a fight the AAFP ought to win.
Who cares?
Let's look at some numbers. There are roughly 220,000 generalists in active practice in the United States, and 400,000 specialists. Of the generalists, more than 90,000 are family physicians, 60,000 of whom are "active" AAFP members. So roughly one in three physicians are generalists, one in seven are FPs, and one in 10 are active members of the Academy. Furthermore, most Americans see one of these generalists every year, and rely on these physicians to shepherd them through a health care system they find perplexing, if not frightening.
That ought to add up to a heckuva lot of clout, but it doesn't. There are lots of reasons.
Not long ago, the four generalist societies got together to figure out an action plan. Rather than howling for financial incentives and administrative simplification for their overworked constituents, they signed onto a concept called the Patient-Centered Medical Home, with a burden of bells and whistles only a bureaucrat could dream up, and love. It might be a painful net gainer for the 25 percent of family physicians laboring in a group of eight or more, but for the rest of us, it just looks like pain, period. Clearly, it was pain to the 36 practices participating in the TransforMed national demonstration project, according to the researchers' first report.
But those of us in the trenches share the blame. When the RUC meets, the specialists have spent a fortune to demonstrate why their procedures are going to save the world. We don't contribute the money that is necessary for effective lobbying.
And then there's the issue of apathy, or resignation. I recently read that almost a third of family physicians had never heard of the Medical Home. If true, that's almost unbelievable. You'd think from reading a few excellent blogs from family physicians (see bar to right) that we know the score; but we're talking mostly to each other, and a relatively small coterie of enthusiasts.
So who cares?
Posted at 03:12PM May 12, 2009 by Doug Iliff | Comments[3]
No-man's land
At the moment I am attending a seminar sponsored by the Kansas Medical Society entitled “Revitalize Your Medical Practice: Creating a High-Performance Work Team.” The nationally-known speaker is a guy like me – about my age (60), and a graduate of a family practice residency and teaching fellowship. The differences are that Harvard Medical School turned me down, and I returned to family medicine after six years in the emergency room. He stayed.
He makes a number of well-researched points that are worth considering in detail, but here’s an important one: The four critical competencies for physicians in 2009 are clinical ability, productivity, teamwork and bedside manner.
This blog is dedicated to the second of those four, and he mentioned in passing that some office-based physicians seem to be under the misimpression that they are owed a living for seeing 10 patients a day. This echoed something TransforMed’s Jim Arend told me a couple of years ago: that some of their test practices thought they could make it in family medicine averaging 16 patients per day per doctor.
They can’t. Here’s why.
Aristotle’s Golden Mean (like Jesus’s Golden Rule, Kant’s Categorical Imperative, Mill’s Utilitarianism, and all other deservedly “great” ideas) is only true most of the time. When it comes to practice staffing and structure, the Golden Mean isn’t desirable.
Between micropractice and full speed ahead is no-man's land, a place where you have all the pains of modern clinical practice, and none of the rewards.
Micropractices are the Amish of family medicine: They enjoy the simple pleasures, and accept a lower salary. They are rarely under time pressure, but they file their own insurance claims and empty their own trash.
Most of us see the appeal of that style, but for one reason or another have chosen a different path. We hire people to answer the phones, file the paperwork, and check patients into rooms. The pain comes from managing those people. The rewards are financial, we hope.
With that payroll comes a moment of truth every payday. You, or another person you hire, write a bunch of checks and live on what is left over. The problem with family medicine is that there is not enough left over to attract medical students into our specialty.
Physicians don't get rich unless they manage insurance or pharmaceutical companies. We are all – specialists and generalists alike – piece workers, just like teenagers stitching together Nikes in Sri Lanka. Our "pieces" are charge codes or, as a matter of shorthand, our patients. If we manage physician extenders, we may profit to a small extent from the labor of others. But not much. It's mostly on our backs.
Now the key question: How many patients a day do you have to see before you earn your first nickel? That is, how many patients does it take to simply pay your bills?
The answer to that question depends on a number of variables, but in general it will be in the low teens; say, for the sake of argument, 13. When you get to 14 a day, you're making (a little) money, maybe $100. That's $2,000 per month, right up there with a full-time Wal-Mart greeter.
Bump it up to 18 a day, and you're an average family physician at $120,000 per year. You're keeping the entire profit from those extra five patients. The rent is the same, the staffing is the same; your supply costs went up a little, and everyone is working harder. The medical students still aren't interested.
But let's say you could average 25 per day. Now you're going to need a bigger office, and at least one more nurse, so the break-even is up to 15 patients from 13. But your profit from patients 16 through 25 is $240,000 per year. You can bank it, or you can take more vacation with a lower salary – or you can hire a mid-level, book 30 or 32 patients per day, take more vacation and earn more too.
The medical students are starting to sniff around. You're looking more like a dermatologist every month.
If any financial lessons are learned from TransforMed, this will be one of them. Of course, we knew it all along.
However, somewhere on the road between the wild, woolly and entrepreneurial days of family medicine 40 years ago, and the present-day experience of family practice residency, this commonsense knowledge was lost.
Because I left academic family medicine in 1980, I don't know how we lost it. My residency director semi-retired from a busy practice in upstate New York, where he saw 30 to 40 patients per day. I doubt many STFM members have that sort of experience; what they know and teach is important, and good, but it has not translated into financial success from their disciples.
I have two very close friends from my early years in medical school and private practice, both dentists. They got a thorough schooling in the business of dentistry. They both were grateful for their payback time in military service, because it gave them a chance to build up their practice speed (as they put it, how to turn the burr) before taking out big loans to start their businesses.
I'm afraid that young family physicians still don't get much practical help with business, and to make matters worse, they no longer have mentors who assure them that they can turn the burr without sacrificing the joy of personal relationships. So they join multispecialty and/or hospital-owned groups where their pay has little direct relationship to productivity – and it doesn't matter, because their service is only a loss-leader, a pipeline into the procedural roundabout. Worse, the lack of entrepreneurial incentive makes them resent that same-day patient who really needs to be seen today.
That's a shame. I wish I knew a way out of this wilderness, where I seem like a voice crying. The present incarnation of the Medical Home may help to sort out the inherent problems and inefficiencies of large groups, or it may not. The lobbying efforts of the Academy may wring a 10 percent increase in payments from Medicare or big insurers, or they may not.
All I know is that I'm having a good time in solo practice, and have for 23 years. Come on in; the water's fine!
Posted at 09:39AM May 05, 2009 by Doug Iliff | Comments[5]
