Is Medical Care Getting Worse in America?

[jmj11]

This is one of those philosophical but honest questions.

 

In this age of dwindling reimbursements I see a trend of a) doing more high paying procedures (whether they are needed or not) or b) spending less time with patients so you can see more, both with a target of maintaining salaries. It was easier to make money in medicine 10 years ago than today. I'm talking about PAs, MDs NPs.

 

My contact with primary care is via my own appointments and those of my family (mostly my aging mother and aunt). While I'm very satisfied with my care, my PCP spends plenty of time with me, answers all my questions and etc., the care that my relatives have gotten in the past few years have been deplorable at best.

 

My mother and aunt both live in Tennessee are on medicare and I have to try and help them by remote control. Over the past ten years I've had them see three different practice groups, none better than the one before.

 

So they have their annual 15 minute exams, quick and to the point. During those visits, if they have any concerns they are blown off. My mother went to see her PCP two years ago with fairly severe LLQ pain for two weeks. Her PCP literally got pissed at her and yelled at her for coming in. He told her "I don't have time for complaints like this, that is what the ER is for. The ER gets paid the big bucks for complaints like this." So she did go the the ER and eventually was dx with diverticulitis. But that is example of what I mean.

 

My aunt is suffering from dementia and it is of recent onset. The problem is that she is also a diabetic and can't remember how to use her insulin. She has passed out from hypoglycemia several times because she took her NPH twice. We, as a family, are working on finding arrangements for her. But she has been to her PCP and endocrinologist several times, after I've called them or wrote them to explain the situation and they have never addressed it. They come in for 5 minutes. Look over her vitals. Say, "good job, see you in a year." But they never discuss the problems they are having and seem pissed if they ask questions or bring up problems. The endocrinologist fired her last Friday for forgetting her appointment. I spoke to his office manager this morning to explain that it is her dementia and they said it didn't matter, they are never seeing her back for no-showing two appointments in the past year.

 

If this was one doctor I would let it go. But it is a pattern. I did eventually have my mother see a NP at her gastroenterologist's office (her diverticulitis has recurred) and had better results where she could ask questions and get answers.

 

But do you think this is a trend? Is it true that rather than seeing 18 patients per day, the provider must now see 28 to keep the same income . . . thus not having time to address any type of chronic problem?

 

I've seen it locally too. I have a lady who comes in and her blood pressures are almost always >200/>100. She is diabetic and he A1 Cs are about 8.8. I'm her headache guy but I'm worried about her. She is on an ACE-I by her PCP, but I've sent her back to him several times. She says he comes in for 5 minutes and makes no changes. I've raised her doses and added migraines preventatives which can lower B/P . . . her her hypertension and diabetes should be my responsibility. I look at his chart notes and her blood pressure is always (meaning every visit for the last two years) as "120/80." What the hell is going on here?

 

So, do you think this is the result of lower reimbursements that the quality of care is going to drop due to the medical-factory mentality of keeping incomes higher?

[jmj11]

This is one of those philosophical but honest questions.

 

In this age of dwindling reimbursements I see a trend of a) doing more high paying procedures (whether they are needed or not) or b) spending less time with patients so you can see more, both with a target of maintaining salaries. It was easier to make money in medicine 10 years ago than today. I'm talking about PAs, MDs NPs.

 

My contact with primary care is via my own appointments and those of my family (mostly my aging mother and aunt). While I'm very satisfied with my care, my PCP spends plenty of time with me, answers all my questions and etc., the care that my relatives have gotten in the past few years have been deplorable at best.

 

My mother and aunt both live in Tennessee are on medicare and I have to try and help them by remote control. Over the past ten years I've had them see three different practice groups, none better than the one before.

 

So they have their annual 15 minute exams, quick and to the point. During those visits, if they have any concerns they are blown off. My mother went to see her PCP two years ago with fairly severe LLQ pain for two weeks. Her PCP literally got pissed at her and yelled at her for coming in. He told her "I don't have time for complaints like this, that is what the ER is for. The ER gets paid the big bucks for complaints like this." So she did go the the ER and eventually was dx with diverticulitis. But that is example of what I mean.

 

My aunt is suffering from dementia and it is of recent onset. The problem is that she is also a diabetic and can't remember how to use her insulin. She has passed out from hypoglycemia several times because she took her NPH twice. We, as a family, are working on finding arrangements for her. But she has been to her PCP and endocrinologist several times, after I've called them or wrote them to explain the situation and they have never addressed it. They come in for 5 minutes. Look over her vitals. Say, "good job, see you in a year." But they never discuss the problems they are having and seem pissed if they ask questions or bring up problems. The endocrinologist fired her last Friday for forgetting her appointment. I spoke to his office manager this morning to explain that it is her dementia and they said it didn't matter, they are never seeing her back for no-showing two appointments in the past year.

 

If this was one doctor I would let it go. But it is a pattern. I did eventually have my mother see a NP at her gastroenterologist's office (her diverticulitis has recurred) and had better results where she could ask questions and get answers.

 

But do you think this is a trend? Is it true that rather than seeing 18 patients per day, the provider must now see 28 to keep the same income . . . thus not having time to address any type of chronic problem?

 

I've seen it locally too. I have a lady who comes in and her blood pressures are almost always >200/>100. She is diabetic and he A1 Cs are about 8.8. I'm her headache guy but I'm worried about her. She is on an ACE-I by her PCP, but I've sent her back to him several times. She says he comes in for 5 minutes and makes no changes. I've raised her doses and added migraines preventatives which can lower B/P . . . her her hypertension and diabetes should be my responsibility. I look at his chart notes and her blood pressure is always (meaning every visit for the last two years) as "120/80." What the hell is going on here?

 

So, do you think this is the result of lower reimbursements that the quality of care is going to drop due to the medical-factory mentality of keeping incomes higher?

[jmj11]

This is one of those philosophical but honest questions.

 

In this age of dwindling reimbursements I see a trend of a) doing more high paying procedures (whether they are needed or not) or b) spending less time with patients so you can see more, both with a target of maintaining salaries. It was easier to make money in medicine 10 years ago than today. I'm talking about PAs, MDs NPs.

 

My contact with primary care is via my own appointments and those of my family (mostly my aging mother and aunt). While I'm very satisfied with my care, my PCP spends plenty of time with me, answers all my questions and etc., the care that my relatives have gotten in the past few years have been deplorable at best.

 

My mother and aunt both live in Tennessee are on medicare and I have to try and help them by remote control. Over the past ten years I've had them see three different practice groups, none better than the one before.

 

So they have their annual 15 minute exams, quick and to the point. During those visits, if they have any concerns they are blown off. My mother went to see her PCP two years ago with fairly severe LLQ pain for two weeks. Her PCP literally got pissed at her and yelled at her for coming in. He told her "I don't have time for complaints like this, that is what the ER is for. The ER gets paid the big bucks for complaints like this." So she did go the the ER and eventually was dx with diverticulitis. But that is example of what I mean.

 

My aunt is suffering from dementia and it is of recent onset. The problem is that she is also a diabetic and can't remember how to use her insulin. She has passed out from hypoglycemia several times because she took her NPH twice. We, as a family, are working on finding arrangements for her. But she has been to her PCP and endocrinologist several times, after I've called them or wrote them to explain the situation and they have never addressed it. They come in for 5 minutes. Look over her vitals. Say, "good job, see you in a year." But they never discuss the problems they are having and seem pissed if they ask questions or bring up problems. The endocrinologist fired her last Friday for forgetting her appointment. I spoke to his office manager this morning to explain that it is her dementia and they said it didn't matter, they are never seeing her back for no-showing two appointments in the past year.

 

If this was one doctor I would let it go. But it is a pattern. I did eventually have my mother see a NP at her gastroenterologist's office (her diverticulitis has recurred) and had better results where she could ask questions and get answers.

 

But do you think this is a trend? Is it true that rather than seeing 18 patients per day, the provider must now see 28 to keep the same income . . . thus not having time to address any type of chronic problem?

 

I've seen it locally too. I have a lady who comes in and her blood pressures are almost always >200/>100. She is diabetic and he A1 Cs are about 8.8. I'm her headache guy but I'm worried about her. She is on an ACE-I by her PCP, but I've sent her back to him several times. She says he comes in for 5 minutes and makes no changes. I've raised her doses and added migraines preventatives which can lower B/P . . . her her hypertension and diabetes should be my responsibility. I look at his chart notes and her blood pressure is always (meaning every visit for the last two years) as "120/80." What the hell is going on here?

 

So, do you think this is the result of lower reimbursements that the quality of care is going to drop due to the medical-factory mentality of keeping incomes higher?

[mdebord]

You are absolutely right. Those of us in Primary Care (PAs, NP, and MDs alike at my office) hate this trend - but our employers won't give us more time with the patients because we'd lose money. Last Monday I saw 14 patients in a morning, most of them follow-ups. Sadly, only the most obvious problems (HTN, DM, etc) got addressed, and then only superficially. Fortunately for me, this is an unusually high volume, but I know some PCPs out there do this routinely. There's just no way you can give good care like that. I'm guilty of getting annoyed when the patient asks a lot of questions or has something "unusual" (read, more time and thought required); I KNOW it's not supposed to be like that - They should ask questions! But I know that if I have to spend extra time on it, I personally will have to make it up later. I clearly see care suffering. I am very big on counseling, usually against overuse of antibiotics or unnecessary treatments, or smoking cessation, preventive care, etc. But on busy days, the sad truth is that patients are more likely to get a Rx, or I won't mention the mammogram they're due for, or they'll get turfed to a Specialist. In spite of all these frustrations, we providers got an email yesterday saying our billings are down. Sadly, I don't think it's so much an issue of individuals trying to keep our incomes high, but more of corporate pressures. There are very few lone Family Doctors left - most of them now work for someone else and do not get a say in scheduling matters.

[mdebord]

You are absolutely right. Those of us in Primary Care (PAs, NP, and MDs alike at my office) hate this trend - but our employers won't give us more time with the patients because we'd lose money. Last Monday I saw 14 patients in a morning, most of them follow-ups. Sadly, only the most obvious problems (HTN, DM, etc) got addressed, and then only superficially. Fortunately for me, this is an unusually high volume, but I know some PCPs out there do this routinely. There's just no way you can give good care like that. I'm guilty of getting annoyed when the patient asks a lot of questions or has something "unusual" (read, more time and thought required); I KNOW it's not supposed to be like that - They should ask questions! But I know that if I have to spend extra time on it, I personally will have to make it up later. I clearly see care suffering. I am very big on counseling, usually against overuse of antibiotics or unnecessary treatments, or smoking cessation, preventive care, etc. But on busy days, the sad truth is that patients are more likely to get a Rx, or I won't mention the mammogram they're due for, or they'll get turfed to a Specialist. In spite of all these frustrations, we providers got an email yesterday saying our billings are down. Sadly, I don't think it's so much an issue of individuals trying to keep our incomes high, but more of corporate pressures. There are very few lone Family Doctors left - most of them now work for someone else and do not get a say in scheduling matters.

[mdebord]

You are absolutely right. Those of us in Primary Care (PAs, NP, and MDs alike at my office) hate this trend - but our employers won't give us more time with the patients because we'd lose money. Last Monday I saw 14 patients in a morning, most of them follow-ups. Sadly, only the most obvious problems (HTN, DM, etc) got addressed, and then only superficially. Fortunately for me, this is an unusually high volume, but I know some PCPs out there do this routinely. There's just no way you can give good care like that. I'm guilty of getting annoyed when the patient asks a lot of questions or has something "unusual" (read, more time and thought required); I KNOW it's not supposed to be like that - They should ask questions! But I know that if I have to spend extra time on it, I personally will have to make it up later. I clearly see care suffering. I am very big on counseling, usually against overuse of antibiotics or unnecessary treatments, or smoking cessation, preventive care, etc. But on busy days, the sad truth is that patients are more likely to get a Rx, or I won't mention the mammogram they're due for, or they'll get turfed to a Specialist. In spite of all these frustrations, we providers got an email yesterday saying our billings are down. Sadly, I don't think it's so much an issue of individuals trying to keep our incomes high, but more of corporate pressures. There are very few lone Family Doctors left - most of them now work for someone else and do not get a say in scheduling matters.

[Teasip]

Modified response. In a nutshell, yes, I think quality of care from the perspective of one-on-one time and personal interaction has deteriorated.

[Teasip]

Modified response. In a nutshell, yes, I think quality of care from the perspective of one-on-one time and personal interaction has deteriorated.

[Teasip]

Modified response. In a nutshell, yes, I think quality of care from the perspective of one-on-one time and personal interaction has deteriorated.

[jmj11]

I think we are going to be forced to either do rapid and lower quality care, go to high procedure fields or, like I'm doing right now, work your butt off (spending long times with each patient) and paying myself peanuts. In my situation, the issue hovering will be job satisfaction. You can only do the later for so long in most cases.

 

I blame a big part of it on the revenues totally wasted on the reimbursement process.

[jmj11]

I think we are going to be forced to either do rapid and lower quality care, go to high procedure fields or, like I'm doing right now, work your butt off (spending long times with each patient) and paying myself peanuts. In my situation, the issue hovering will be job satisfaction. You can only do the later for so long in most cases.

 

I blame a big part of it on the revenues totally wasted on the reimbursement process.

[jmj11]

I think we are going to be forced to either do rapid and lower quality care, go to high procedure fields or, like I'm doing right now, work your butt off (spending long times with each patient) and paying myself peanuts. In my situation, the issue hovering will be job satisfaction. You can only do the later for so long in most cases.

 

I blame a big part of it on the revenues totally wasted on the reimbursement process.

[primadonna22274]

I hope to see a positive change in this over the next 4 years (my clinical year and very likely an unopposed full-spectrum FM residency). Whether I will be able to maintain my personal standards in practice remains to be seen particularly as ACA rolls out in the next year.

I thought long and hard about this. I didn't want to think I had gone to the expense and opportunity costs of med school to "just" do family medicine...I probably will have the board scores to do almost anything I want (if diagnostic exams are truly predictive). The truth is that FM is my first love. It's what I'm good at. Ultimately my career goal is to end up back in medical education on the Clin Ed side. I am passionate about providing individualized, comprehensive and truly excellent care. I believe in prevention. I am not scared of multisystem disease (in fact, having practiced for a dozen years and then learning the detailed pathophysiology behind all of these illnesses, to finally get how the puzzle pieces fit together is pretty darn fascinating). I suppose I am a closet internist but I enjoy seeing all ages and the career flexibility FM provides.

IMHO Mike the kind of care your mother and aunt are getting is bad care. Same goes for your patient with uncontrolled HTN. Her doc's records must be fabricated. This is very concerning to me and I am sure to you as well.

I am not a fan of doing as many procedures as possible just to be reimbursed. Those of us who are primary care-oriented appreciate the cognitive aspects of what we do. It's been traditionally under reimbursed but I do think a sea change is coming.

Keep up the good fight. I appreciate what you do!!

Lisa

[primadonna22274]

I hope to see a positive change in this over the next 4 years (my clinical year and very likely an unopposed full-spectrum FM residency). Whether I will be able to maintain my personal standards in practice remains to be seen particularly as ACA rolls out in the next year.

I thought long and hard about this. I didn't want to think I had gone to the expense and opportunity costs of med school to "just" do family medicine...I probably will have the board scores to do almost anything I want (if diagnostic exams are truly predictive). The truth is that FM is my first love. It's what I'm good at. Ultimately my career goal is to end up back in medical education on the Clin Ed side. I am passionate about providing individualized, comprehensive and truly excellent care. I believe in prevention. I am not scared of multisystem disease (in fact, having practiced for a dozen years and then learning the detailed pathophysiology behind all of these illnesses, to finally get how the puzzle pieces fit together is pretty darn fascinating). I suppose I am a closet internist but I enjoy seeing all ages and the career flexibility FM provides.

IMHO Mike the kind of care your mother and aunt are getting is bad care. Same goes for your patient with uncontrolled HTN. Her doc's records must be fabricated. This is very concerning to me and I am sure to you as well.

I am not a fan of doing as many procedures as possible just to be reimbursed. Those of us who are primary care-oriented appreciate the cognitive aspects of what we do. It's been traditionally under reimbursed but I do think a sea change is coming.

Keep up the good fight. I appreciate what you do!!

Lisa

[primadonna22274]

I hope to see a positive change in this over the next 4 years (my clinical year and very likely an unopposed full-spectrum FM residency). Whether I will be able to maintain my personal standards in practice remains to be seen particularly as ACA rolls out in the next year.

I thought long and hard about this. I didn't want to think I had gone to the expense and opportunity costs of med school to "just" do family medicine...I probably will have the board scores to do almost anything I want (if diagnostic exams are truly predictive). The truth is that FM is my first love. It's what I'm good at. Ultimately my career goal is to end up back in medical education on the Clin Ed side. I am passionate about providing individualized, comprehensive and truly excellent care. I believe in prevention. I am not scared of multisystem disease (in fact, having practiced for a dozen years and then learning the detailed pathophysiology behind all of these illnesses, to finally get how the puzzle pieces fit together is pretty darn fascinating). I suppose I am a closet internist but I enjoy seeing all ages and the career flexibility FM provides.

IMHO Mike the kind of care your mother and aunt are getting is bad care. Same goes for your patient with uncontrolled HTN. Her doc's records must be fabricated. This is very concerning to me and I am sure to you as well.

I am not a fan of doing as many procedures as possible just to be reimbursed. Those of us who are primary care-oriented appreciate the cognitive aspects of what we do. It's been traditionally under reimbursed but I do think a sea change is coming.

Keep up the good fight. I appreciate what you do!!

Lisa

[cupojava]

I hope not. Firstly, your mom's PCP showed blatant unprofessionalism and should be reported to the state board. I mean, how easy would it have been to get the labs done, call the ER provider and say "I got a really sick pt here. I'm sending her to you." The ER guys usually are thankful for the heads up. Secondly, time constraints might be more applicable in corporations, not smaller clinics, IMHO. I am in FP and I see combination of walk ins and appts. I address their BP even when I'm just seeing them for cough and colds. My nurses often say, why are we doing all these work up if we might not have to see them again! My generic answer- do unto others. I also think that any visit is a chance to vaccinate. So I do that as long as they don't have contraindications. Can't get them in for well visits, here's the alternative. Yeah, some people wait but are very appreciative when the provider cares enough to spend time with them. Sure, sometimes I get frustrated but who doesn't? We shouldn't take it out on the pts who rely on us. I will find the time for my patients. There are still some of us who love what we do here in FP land.

[cupojava]

I hope not. Firstly, your mom's PCP showed blatant unprofessionalism and should be reported to the state board. I mean, how easy would it have been to get the labs done, call the ER provider and say "I got a really sick pt here. I'm sending her to you." The ER guys usually are thankful for the heads up. Secondly, time constraints might be more applicable in corporations, not smaller clinics, IMHO. I am in FP and I see combination of walk ins and appts. I address their BP even when I'm just seeing them for cough and colds. My nurses often say, why are we doing all these work up if we might not have to see them again! My generic answer- do unto others. I also think that any visit is a chance to vaccinate. So I do that as long as they don't have contraindications. Can't get them in for well visits, here's the alternative. Yeah, some people wait but are very appreciative when the provider cares enough to spend time with them. Sure, sometimes I get frustrated but who doesn't? We shouldn't take it out on the pts who rely on us. I will find the time for my patients. There are still some of us who love what we do here in FP land.

[cupojava]

I hope not. Firstly, your mom's PCP showed blatant unprofessionalism and should be reported to the state board. I mean, how easy would it have been to get the labs done, call the ER provider and say "I got a really sick pt here. I'm sending her to you." The ER guys usually are thankful for the heads up. Secondly, time constraints might be more applicable in corporations, not smaller clinics, IMHO. I am in FP and I see combination of walk ins and appts. I address their BP even when I'm just seeing them for cough and colds. My nurses often say, why are we doing all these work up if we might not have to see them again! My generic answer- do unto others. I also think that any visit is a chance to vaccinate. So I do that as long as they don't have contraindications. Can't get them in for well visits, here's the alternative. Yeah, some people wait but are very appreciative when the provider cares enough to spend time with them. Sure, sometimes I get frustrated but who doesn't? We shouldn't take it out on the pts who rely on us. I will find the time for my patients. There are still some of us who love what we do here in FP land.

[primadonna22274]

Cupojava, you are my kind of FM PA :)

[primadonna22274]

Cupojava, you are my kind of FM PA :)

[primadonna22274]

Cupojava, you are my kind of FM PA :)

[EMEDPA]

Primma- wouldn't it be funny if 10 years from now you were medical director of a pa program I was the clinical coordinator of?.....:)

[EMEDPA]

Primma- wouldn't it be funny if 10 years from now you were medical director of a pa program I was the clinical coordinator of?.....:)

[EMEDPA]

Primma- wouldn't it be funny if 10 years from now you were medical director of a pa program I was the clinical coordinator of?.....:)

[primadonna22274]

That would be the BESTEST program E! You, me, my dear friend Laura (now at Nova), Les and we could (try) to get RC to move west :)