| |
|
|
Improving healthcare through entrepreneurship |
Follow | Share | Learn
|
|
    |
||
|
|
||
| |
Category : Economics
Is traditional internal medicine dead? – A guest post by Dr. Steven Knope
Introduction by Tannus Quatre PT, MBA
I am pleased to post the following commentary from Dr. Steven Knope, an internal medicine specialist and concierge physician located in Tucson, AZ. I had the pleasure of befriending Dr. Knope a few years ago, and since that time have enjoyed thoroughly Dr. Knope’s perspective on medicine, and vision for the future of healthcare. Dr. Knope’s book, Concierge Medicine: A New System To Get The Best Healthcare, is an excellent read and an important lens through which our country’s current struggles with delivering the best healthcare can (and should) be viewed.
A true healthcare entrepreneur, it’s my privilege to post the following commentary from Dr. Knope titled, “Is Traditional Internal Medicine Dead?”
_____________________________________________________________________________
Is Traditional Internal Medicine Dead?
by Steven Knope, MD
For the last several years, writers in the New England Journal of Medicine and the Journal of the American Medical Association have authored doomsday editorials about the prognosis of primary care medicine. There has been much discussion about the fact that internists and family practitioners cannot keep pace with rising overheads and falling reimbursement under the traditional third-party payment system. Paraphrasing a recent story published in The New York Times, an internist in Massachusetts who practices under the new RomneyCare program said this: “Every time I see a Medicare patient, it is the equivalent of giving them a ten-dollar bill. I have a six month wait to see a new patient. I run from room-to-room. I can barely make my overhead. I’ve never felt so disrespected in my entire life.”
So is this all just whining and political hyperbole or is internal medicine really dying? The answer to this question was revealed to me by a colleague last weekend while I was at the hospital. I had been called to the ER for one of my patients who was hemorrhaging on the blood thinner, Coumadin. The ER doctor looked at me and said, “You are a dying breed.” I laughed and said, “Yes, I know…but why do you say this?” He responded, “See that list of 9 doctors’ names and phone numbers up there on the wall? You are one of the last of 9 doctors who still admits his own patients to this hospital when they get sick. All of the other internists and family practitioners have abandoned hospital medicine and limit their practice to the office.” I knew that this was a profound statement and it shocked me; but I did not fully digest its implications until I had stabilized my patient and started my drive home.
The hospital where I practice has over 700 doctors on staff. The fact that only 9 of us still take care of our own patients when they are hospitalized answered the question about internal medicine’s future. It is no longer an issue of whether traditional internal medicine can survive; the facts are – at least outside of the concierge model – internal medicine is already dead.
What are the consequences for patients? What happens to the average person in Tucson, Arizona when he or she gets chest pain, develops pneumonia or has a seizure? Can they reach their internist or family practitioner for a medical emergency? Most patients who call their primary care doctor for a medical emergency can’t even reach his staff during normal office hours. Instead, they will hear a recording on an answering machine, directing them to go to “call 911” for any medical emergency.
Once in the ER, the “doctorless” patient will be admitted to a hospital physician, who is unknown to them. This so-called “hospitalist”, who is a salaried shift-worker, will put in his 12 hours, and then go home. He is a doctor who knows nothing about the patient’s medical history. He has never met the patient. There will be no call from the hospital doctor to the primary care doctor in the office to get a thorough medical history. There will be no medical records transferred to the hospitalist. The hospitalist will attempt to get the best medical history he can from the patient, make some quick medical decisions, and then pass the patient off to one of his colleagues when his shift ends. And so it goes. No continuity of care, no understanding of the patient; the sick person now becomes a “case of pneumonia” or “the stroke in bed 3” to a group of unknown, rotating professionals.
As fewer and fewer young doctors go into internal medicine and family practice, and thousands of primary care doctors retire early due to financial pressures, the primary care shortage will only worsen. Not only will there be no primary internists to take care of their own patients in the hospital, there will be fewer internists available to see patients in the office setting. This inevitable vacuum of internists and family practitioners (traditional diagnosticians) will be filled by nurse practitioners and medical assistants; people with far less training and expertise than an M.D.. If you are fortunate enough to have a good nurse practitioner, you will eventually be referred to an appropriate specialist, who will treat one of your medical problems. If you are not so lucky, a nurse or medical assistant may miss an uncommon or rare diagnosis; he or she may misdiagnose the “headache” that is actually an aneurysm, the “flu symptoms” that turn out to be meningitis, or the “gallbladder problem” that turns out to be a heart attack. Bad things will inevitably happen when doctors are replaced by medical assistants. It is simply a matter of statistics. All doctors make mistakes, but those with less training make more.
As a concierge physician, people often ask me how this move toward a government-run healthcare system will affect me professionally. Speaking honestly, I tell them that it will help my practice, but I do not think this is good news for the country. As an independent concierge doctor, I am not subject to the rules or fees set by Medicare or Medicaid, nor do I deal with third-party insurance carriers or HMOs. I work for my patients, not a third-party with a conflicting financial agenda. As someone who practices full-service internal medicine, the demand for my services will continue to increase. However, this outlook about my own practice does not make me happy. I have small children. I am concerned about their future. I am concerned about what the changes in primary care will do the future of American medicine; what will happen if the art of internal medicine is completely lost. I am worried about what it will mean to the efficiency of medicine as a whole, to have no diagnosticians and clinicians to treat the majority of problems that do not need a specialist.
I have found a unique niche in medicine, which allows me to truly practice what I was trained to do. For most of my colleagues, however, this is no longer the case. They too were trained to care for patients from the office, to the hospital, to the ICU. Now, they no can longer afford to take care for their patients when they develop life-threatening illnesses. They are now “clinic doctors.” Their hospital skills have atrophied. They will never practice comprehensive medicine again. For them, the game is already over. For them, internal medicine is already dead. For their patients, and the society as a whole, this is a great loss.
More physicians leave private practice
I was recently interviewed for an article which was published in the Carolina Journalism Network, titled “Physicians move out of private practice,” a story by Laura Montini. The interview was prompted by an article I wrote for The Healthcare Entrepreneur Blog titled, “Time to throw in the towel on private practice…or is it?”
Click here to visit the article (excerpt below).
As an advocate of entrepreneurship, Quatre said that doctors should not lose hope on keeping their private practices afloat.
“When the owner of a practice has a vested interest in seeing the practice succeed, that’s an equation where incentives are alive in a way that has a real natural benefit to the community,” Quatre said.
There is still a place for more entrepreneurial practice owners in health care, he said.
“It’s not time to throw in the towel.”
Via: Physicians move out of private practice | Carolina Journalism Network.
Time to throw in the towel on private practice…or is it?
I don’t buy it.
An article in the New York Times today titled, “More Doctors Giving Up Private Practices,” told the story of an increasing number of physicians who are finding their “bliss” through employed, salaried positions, rather than at the helm of their own private practice. The reason – increased costs, decreased pay, and ultimately unhappier doctors in the private practice environment. Again, I don’t buy it.
The article spoke of the increasing financial burden on physicians who, in order to keep up with the demands of today’s healthcare arena, must invest heavily into expensive electronic medical record systems (EMR) and practice management softare (PMS), along with the staff required to collect payment from a growing number of patients who lack the financial wherewithal to pay their bills. Sure, the challenges are real, but it’s still bullhonkey.
The silver lining in this shift toward larger, safer, and inevitably more monopolized healthcare practice – if there is one – the article goes on to say, is the continuum of care that is far facilitated by larger, more integrated systems which employ large numbers of physicians from a variety of specialties. Not convinced.
The Medical Group Management Association (MGMA) reports - according to the article - that in 2005 more than 67% of medical practices were physician owned, however three short years later this number had dropped to below 50%. With admitedly disturbing facts such as this, and the industry knowledge that is near and dear to my heart – that private practice owners are, in fact, struggling in pockets across the country – how could I possibly scoff at the fact that an article in the New York Times suggests that quite possibly it is time to throw in the towel by the physician masses?
Because it’s short sighted, cowardly, and undermines the creative and entrepreneurial fabric from which many of our country’s greatest practices are woven.
In a nutshell, it’s the wrong way to go.
I’ve been around healthcare my entire life, and my professional career has known nothing else. I care deeply about people, and understand that passion, freedom, autonomy, and creativity are the inspiration behind the greatest care that our country can offer. I also understand that in order to attain autonomy, passion, freedom, and creativity requires risk, hard work, and often times, failure.
I’ve worked salaried positions and have spent much of my life in a risk averse bubble, looking fondly at the status quo and fearing anything that risked upsetting it.
But I’ve also lived the other side. The side that guarantees nothing, but promises everything. The side that allows me to be exactly who I’ve been created to be, and to relish in failure as it is a means by which I will improve my service to others. It is this side about which I am passionate, and about which I know I can change my life, the lives of others, and through my current mission with Vantage Clinical Solutions, change healthcare.
I don’t think the healthcare industry is going to benefit from bigger companies who can promise the world to its salaried professionals, while placing handcuffs on the passion and creativity that comes only with the ability to chart one’s own professional course. I don’t think the continuity of care is going to suffer if small town doctors have to refer to one another rather than down the hall in order to provide the specialty care that is needed of their patients. And I don’t think that failure is inevitable to those who try to make it work.
There are challenges, yes. We, at Vantage Clinical Solutions help private practice owners deal with them everyday. We feel the pressures of the economy just like the next guy. The difference is that we see the challenges as an opportunity to look to entrepreneurship, creativity, and innovation as the tool from which our problems will be fixed.
We understand that the “corporate” way which benefits from huge economies of scale and infrastructural efficiencies does indeed have merit – but more importantly we know that it is not the only answer. We work with numerous private practice owners every day who are delivering healthcare their way, doing it profitably, and changing their patients’ lives in the process.
At the risk of belaboring my diatribe of a post, I do want to make clear that I understand that entrepreneurship indeed is not for everyone, and the thousands upon thousands of professional, caring, and excellent healthcare providers who do thrive in the corporate, structured environment, need not change a thing. Indeed, consolidation and centralization is a viable solution to many of the challenges we face in the healthcare industry.
My point, however, is to suggest that it is not the only solution, and to those who’s fuel does come from a burning passion to create, be different, and deliver care in their own way – bear down and get after it.
The system that the NY Times article speaks of is not for you.
Vantage Forums: Health Insurance Coverage by State
The US Census Bureau has tons of great information that can be used to perform effective market analysis. One area that we didn’t cover in detail during the Market Analysis 101 presentation was the ability to obtain information on the health insured in the US.
This page (http://www.census.gov/hhes/www/hlthins/ … index.html) of the US Census website provides links to historical health insurance tables which break down the insured and uninsured by state, age, historical year, type of insurance, and more. It’s a great resource.
via Vantage Forums: Health Insurance Coverage by State.
Vantage Forums: County Health Rankings Website
During a recent Market Analysis presentation at CSM 2010, I mentioned a website link that was referenced in a recent email by the APTA. The website is called “County Health Rankings” and the url is www.countyhealthrankings.org. This is an excellent resource for market health data at the county level and provides a number of data categories as well as an explanation of the data collection methodology and relevance for each. Really a great resource and I recommend you bookmark it…remember, data is EVERYWHERE!
via Vantage Forums: County Health Rankings Website.
$15 million Medicare fraud scheme paid kickbacks to fraudulent patients
Two Miami residents have plead guilty to submitting over $15 million in false and fraudulent claims to Medicare for heathcare services that were either not necessary or not provided from March 2006 through March 2007. By itself this is a tragic tale, but the fact that the criminals paid cash and narcotic kickbacks to Medicare beneficiaries in return for their co-conspiracy in the fraud scheme is disgusting.
In his plea, Jose Rosario also admitted that Medicare beneficiaries were neither referred to Sacred Hope by their primary care physicians, nor for any other legitimate medical purpose, but rather were recruited to come to the clinic through the payment of kickbacks. In exchange for their kickbacks, the Medicare beneficiaries would visit the clinic and sign documents falsely indicating that they had received the services billed to Medicare. According to information contained in the plea documents, kickbacks came in the form of cash and prescriptions for narcotic drugs. Jose Rosario admitted he directed his nephew, co-defendant Arnaldo Rosario, to oversee and facilitate the payment of cash kickbacks to the Medicare beneficiaries. Jose Rosario admitted that he would routinely obtain cash that he would provide to Arnaldo Rosario for the purpose of paying the beneficiaries cash kickbacks.
And, this is just the tip of the iceberg. The Miami case was brought forward by the Medicare Fraud Strike Force, who since their inception in March 2007, have obtained indictments of nearly 300 persons and organizations that have billed Medicare close to $700 million.
Click to read the full article from the USDOJ
Loss of obstetric services forces NY patients elsewhere
For those that think the growing physician shortage is strictly a Medicare issue, think again.
What happens when a young, middle-class mother wants to deliver a baby in Hamilton, NY? After August 31st, it’ll mean a drive out of the area due to a closure of the OB department at Community Memorial Hospital.
The reason – not enough qualified providers to provide the service.
“It’s certainly a significant loss for the community,” said David Felton, hospital president and chief executive officer. “People will be forced elsewhere to deliver babies, and that’s very unfortunate.”
via Hamilton hospital to close down its obstetric services – Utica, NY – The Observer-Dispatch.
Nurse Practitioners As Primary Care Doctors
Some estimate that as many as 125,000 nurse practitioners throughout the U.S. might have a sizable impact on the primary care shortage. In Boston, wait times are about as bad as they get, providing the impetus for finding a solution quickly.
Trying to get an appointment to see your primary care doctor can be a burden. In Boston, the wait time to see a physician is the worst in the country, with an average of almost 50 days.
via Nurse Practitioners Can Practice As Primary Care Doctors.
Interstate competition for primary care doctors
Competition for a shrinking pool of qualified primary care doctors is hurting states that have a hard time recruiting against higher paying markets. For Vermont, the lure of a high quality of life isn’t quite enough it seems.
The reasons for the doctor shortage, which has been gradually worsening over the years, are well documented. Much of the problem boils down to money. Medical students who opt to specialize rather than enter primary care practices stand to make significantly more because specific procedures earn higher reimbursements than generalized care and diagnoses. For medical students leaving school with debt loads often topping $150,000, the decision to enter primary care practice often means a degree of financial hardship, according to survey-based research conducted in Vermont and nationwide.
Exerpted from: Doctor shortage proves painful to state: Times Argus Online.
Recruiting physicians to rural areas means keeping the family happy
When hospitals can’t pay physicians enough to practice in rural areas, the focus turns to keeping the spouses and children happy.
“Rural areas and smaller cities—depending on the impact the economy is having on them—they are being extremely creative” in their recruiting, says Kathy Murray, senior director of key accounts at St. Louis-based Cejka Search, adding that this is especially true for specialists such as orthopedic surgeons whose procedures are major cash generators. “They are bringing in significant amounts of revenue into a hospital system, and they are going to do whatever it takes to get them there.”
Murray says that this includes recruiting doctors earlier in their training and keeping the physicians’ families happy.
“If it’s a two-income family, I’ve seen organizations help the spouse look for a position,” Murray says. “A physician can generally practice any place. Their family, though, has to be happy or it becomes a retention issue.”
Recent Comments