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It’s 4:57 p.m., and the Doctor is not picking up the phone

It’s 4:57 p.m., and the Doctor is not picking up the phone

That’s the format of a joke I often told about calling up state regulators when I was in private practice. They go off duty at 5 p.m., so the phone stops being answered at a few minutes before because a conversation started at 4:57 p.m. might go beyond 5 p.m., and they don’t get paid for that.

It’s coming to a doctor near you because Obamacare regulations are pushing doctors to become employees rather than owners, as Scott Gottlieb writes in The Wall Street Journal, The Doctor Won’t See You Now. He’s Clocked Out:

Big government likes big providers. That’s why ObamaCare is gradually making the local doctor-owned medical practice a relic. In the not too distant future, most physicians will be hourly wage earners, likely employed by a hospital chain….

ObamaCare’s main vehicle for ending the autonomous, private delivery of medicine is the hospital-owned “accountable care organization.” The idea is to turn doctors into hospital employees and pay them flat rates that uncouple their income from how much care they deliver. (Ending the fee-for-service payment model is supposed to eliminate doctors’ financial incentives to perform extraneous procedures.)The Obama administration also imposes new costs on physicians who remain independent—for example, mandating that all medical offices install expensive information-technology systems.

The result? It is estimated that by next year, about 50% of U.S. doctors will be working for a hospital or hospital-owned health system. A recent survey by the Medical Group Management Association shows a nearly 75% increase in the number of active doctors employed by hospitals or hospital systems since 2000, reflecting a trend that sharply accelerated around the time that ObamaCare was enacted. The biggest shifts are in specialties such as cardiology and oncology.

Read the whole thing. It explains how this structure alters physician behaviors, and how the esoteric and complicated billing structure exacerbates the situation.

I had dinner this weekend with a physician in private practice, who bemoaned the changes taking place and how much time he has to spend on “all that crap” other than practicing medicine. He doesn’t know how much longer he can take it, a feeling he says is common among his peers. They’re planning their exit strategies.


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9thDistrictNeighbor | March 27, 2013 at 11:38 am

I once asked a surgeon when the best time to practice medicine was–his reply was in the 1960s…before all of the paperwork requirements.

Around us, all of the empty storefronts (Borders books, closed furniture showrooms, etc.) have been sucked up by the huge hospital chains for their practices.

This giant corporate/government employment of physicians smacks of the Soviet Union.

    Not the Soviet Union…

    Think Germany or Italy.

    Fascist economics is what Obama loves, and what this is. The model HATES small entrepreneurial businesses, and fosters BIG, compliant ones.

    Interestingly, the counter-stroke here is MORE market economics, as many doctors are becoming “boutique” practitioners who only practice for actual money, NOT the chance to charge your insurance carrier or the government.

      If I could “like” that a thousand times, I would. The Obamacare system is going to create a two-tiered system:
      A cash-for-care system to those who have the means. For everyone else, a vast bureaucracy, a nightmare of rationed care by doctors overworked, underpaid, who will end of being treated like government stooges, will have the attitude – and likely the aptitude – of union, DOT bureaucrats.

        david7134 in reply to McCoy2k. | March 27, 2013 at 12:23 pm

        No, you are incorrect in the assumption. They will make it against the law to work outside the system. So even if you have the cash, you will not get what you want, unless you are one of the elite.

          Ragspierre in reply to david7134. | March 27, 2013 at 12:27 pm

          Disagree, but prohibition never works.

          Civil disobedience works every time it is popularly supported.

          ThomasD in reply to david7134. | March 27, 2013 at 4:20 pm

          They won’t make it illegal, but what will happen is that the free agents will be locked out of the hospital systems through the credentialing process. They will have to hand off ‘their’ patients to the system’s staff hospitalists. At which point many patients will never return to the independents.

          Ragspierre in reply to david7134. | March 27, 2013 at 5:47 pm

          Ah, but remember…

          there are other places in the world to go to hospital.

          You’re right in correcting me. I did not state in plain and specific language what I should have. I did mean exactly as you say: that there would be a system for the “elite”, the “party people”, and another for everybody else. When I say “party people” I mean people are special in the Democrats political coalition. In other words, people who willingly hand over cash to Democrats campaigns and their ideological projects.

        Ragspierre in reply to McCoy2k. | March 27, 2013 at 12:25 pm

        Also, as we’re seeing in Kulhifornia, increasingly it will be…

        “The NOT-doctor will see you now”, as the dearth of qualified providers will push care down into lower and lower levels of care-givers.

      jdkchem in reply to Ragspierre. | March 27, 2013 at 2:19 pm

      In Russia doctors still make house calls. It may not be today or tomorrow but they will eventually get to your home. My wife says they operate a bit like comcast except with a 48 hour or more window.

        Ragspierre in reply to jdkchem. | March 27, 2013 at 2:55 pm

        I read a little blurb the other day, saying that the 21st Century will…if we let it…bring the Medical Revolution.

        We are very close to enormous break-throughs, including a “tri-corder” a la Star-Trek.

        Right now, some boutique doctors are using emails to help them provide service. With Skype and the like, they can do a lot via computer.

        The market will continue to innovate. One of the worst thing for that is a rigid structure that impedes that innovation, which is ObamaCare in spades.

You ain’t seen nothing yet. Doctors have not been able to form a union as they were independent operators. As employees, they will be unionized. Then the poop will hit the fan. We have not been adequately compensated for at least 15 years and will be making up for lost ground. As to not picking up the phone, you can forget that nonsence, we will not be talking on the phone.

Tell me about it. Last week I was in town and all of a sudden the fingers of my left hand turned white and got numb; I thought I had a blood clot or something. Since I was only a block away from my doctor’s office, I went in there and told the receptionist what was going on. One of his technicians took me back to an exam room, wrote down my “story”, and took it to the doctor. About 30 minutes later she returned and told me “The doctor can’t see you today but you should be evaluated at the ER.”

So I went to the ER and five hours later I finally got to see the physician. All the symptoms were gone by then and he didn’t have any idea what had caused my problem. He didn’t do any tests or even listen to my heart with his stethoscope.

For this I wasted an entire day and will be charged for an ER visit? Welcome to Obamacare!

    david7134 in reply to snopercod. | March 27, 2013 at 12:17 pm

    You actually received adequate, timely care compared to what it will be like in a few years. There is no incentive for a doctor to care about your situation. You can claim humanity, but you lose that because of the malpractice situation. Certainly the doctor is not getting compensated.

    As to what happen, you had vascular spasm. Likely brought on by the cold. Only a problem if it continues to happen.

      snopercod in reply to david7134. | March 27, 2013 at 2:37 pm

      There is no incentive for a doctor to care about your situation.

      Is money no longer an incentive for doctors?

      Thanks for the diagnosis. That’s more than I got for spending (probably) $1,000 at the ER.

Yes, it will happen and has happened before. I worked for a large HMO who employed the doctor’s group I was actually paid by. I did echocardiograms. One day I had a gentleman come in late in the afternoon. He was extremely difficult to image due to his size and smoking history but I could see that he was in serious trouble. I went to the doc who was there for the day and told him not to leave yet as this man might need transport to the ER. He was angry that I asked him to stay past 4:30 even though he was supposed to be until 5 PM. Long story short, he totally dismissed my opinion about what I was seeing, told the man it wasn’t serious and to check back if he got worse and left, grousing to my co-workers that I had made him late for a dinner appointment with my “diagnosis.” I was infuriated but what could I say? I told the man and his daughter to be sure and check back with his doctor soon if he didn’t get better.

I showed that echo to several other docs who followed (they rotated to our facility) and everyone agreed it needed follow up but no one wanted to contradict another doctor. So I waited and watched the ER admissions. Sure enough, three weeks later he was admitted to the hospital and rushed to surgery for a valve replacement. Except that now a second valve was involved (he had an infection of the heart valves). He died a year later, having never fully recovered from the trauma of an emergency heart surgery and his other physical ailments that impaired his recovery.

I have often wondered what would have transpired had the man had an early morning appointment. Would the doc have been so eager to dismiss my findings? I’ll never know but I do know that had that doctor not been employed by the hour, if he had to depend on his patients to like him enough to return to him, that man might have lived a longer life. I haven’t quite forgiven myself, either.

I’ve cured a couple of ailments on my own over the past several years. I go to http://www.earthclinic to find natural remedies – and they worked! Of course, if need be, I’ll go to my doctor. I’m presently trying to find a doctor who does integrative medicine.

How far are we then from drive-thru breast enlargement? Super size me will have a whole new meaning!

I am a doctor whose group sold out in February 2011. Our incomes (cardiologists) are plunging, and Washington’s requirements are indeed very expensive (though they assert it will save money). I am thankful that I have already saved a lot of money. Ready to move into administration.

Eventually you will notice that quality will go down, this will result in quotas where a doc can only see so many people in a day. In theory it gives docs more time to spend with patients. In practice, your local clinic may close at noon because the quota has been met.

This is pretty common here in Canada.

Someone please tell me why we didn’t do a thorough review of different ways of improving medical care instead of just ramming through this monstrosity? I really don’t understand – I understand the mindset of control (well, sort of) but who in their right mind would want to hurt people on purpose? We have enough evidence that single payer won’t work. Why are we bound and determined to do it here? And why aren’t we out in the streets by the millions voicing our displeasure? Are we really that stupid?

I filled the feeder with hay for the sheep this morning. I felt sorry for two of the smaller ewes who were being pushed off the hay so I took a flake and dropped it out about 30 feet from the feeder, thinking those two would see it and go to it. Oh, they did. But so did the other 12! There they were, pushing and shoving each other over that one flake of hay when the feeder stood empty with four flakes for the taking. I said, “Have at it” and left, laughing. But here we are – the sheeple, following each other from one disaster to another, putting up little red equal signs on our Facebook profiles like the good little sheep that we are. I’m disgusted with my species!

    Ragspierre in reply to JoAnne. | March 27, 2013 at 4:01 pm

    “Someone please tell me why we didn’t do a thorough review of different ways of improving medical care instead of just ramming through this monstrosity?”

    Because it was NEVER about health care. It was about POWER.

      bawatkins in reply to Ragspierre. | March 27, 2013 at 4:20 pm

      Wealth is power, so when the government controls all the wealth, it has all the power. Obamacare is a useful means to this end.

    ThomasD in reply to JoAnne. | March 27, 2013 at 4:37 pm

    You have an incentive to see that those runts get fed in order that they grow, thrive, and produce on your farm.

    Some would like to think the government will look out for your health in the same manner. Which, at best, makes you their property.

    Conversely if your livestock did not have any potential you would not expend extra resources and either let nature take it’s course, or humanely dispatch them sooner. Never mind what becomes of those ‘citizens’ who are deemed nonproductive.

    “… who in their right mind would want to hurt people on purpose?” Democrats and liberals, that’s who. That’s how they keep Blacks on the plantation. That’s how they keep the low hanging fruit in chains with SSI, free cell phones and voting democrat.

Henry Hawkins | March 27, 2013 at 4:37 pm

Who works harder, the person on salary receiving the same amount regardless of effort, or the person on commission, receiving a percentage only on actual work done?

Obamacare moves doctors from the latter to the former.

For every 1 Obamacare doctor there will be 100 utilization review government bureaucrats cooking the numbers on productivity.

I’m fortunate to be one of those dinosaurs whose practice model still enables me to answer that phone 24/7. But the private, independent practice of medicine will continue to shrink as hospital survival incentives encourage bringing all physician practice under the hospital umbrella, into what they call ‘accountable care organizations’. Just saw an article this morning the nearly 50% of physicians are already employed directly or indirectly by hospital systems. The new paradigm will put physicians in several binds. One, the physician will be an expensive cost center. If the physician really puts the patient’s interests first, even more so. But the hospital depends on the physician (well, any licensed ‘provider’ they can get to do it) for referrals into the system to maximize gross revenue. So the long-traditional love-hate relationship between hospitals and physicians will continue, only now the hospital will control the money – unless the physician ‘behaves’, he/she will be out of a job. The tension between financially independent entities worked to the benefit of patients, but it will ‘my way or the highway’ from now on. What was once a proud profession (deservedly so) is rapidly become a trade. Don’t get me wrong, trades are good for many things, but those of us educated to utilize our assessment skills and individualized independent judgment in the service of our patients don’t fit well into the trade paradigm. In the new order, the customers will be ‘diabetes’, ‘hypertension’, ‘coronary disease’, ‘lung cancer’, etc., rather than unique human beings.

My primary care physician sees me the day that I call, if it is before 3:00. After 3:00, I am seen the next morning. I can understand that. What baffles me is that Medicare pays him about 25% of what he submits and what he submits seems very reasonable.
My concern is for my children and grandchildren. They will suffer under the boot of ObamaCare.
The “elites” [democrats and wealthy republicans] will have all of the healthcare that they need and want.

Mister Natural | March 28, 2013 at 10:57 am

Here’s what’s coming gang

Man dies after doc takes lunch during kidney op
Published: 6 Sep 12 11:44 CET | Print version

A 72-year-old man having a tumour removed from his kidney died after the chief anesthetist and nurse took a lunch break in the middle of the surgery.
The incident, which took place at the Lidköping hospital, has prompted stinging criticism from Sweden’s National Board of Health and Welfare (Socialstyrelsen).

The 72-year-old went under anesthetic at 10.45am on the day of the operation, which took place in January 2011.

At noon sharp, the head anesthetist left the operating room to go for lunch. Fifteen minutes later, the head nurse anesthetist also left the patient and went for lunch.

No other anesthetist was called in to take over responsibility for the doctor who was on his lunch break.

And while another nurse was brought in to cover for the nurse anesthetist, the nurse who arrived came from the orthopedic ward and wasn’t familiar with the respirator to which the 72-year-old was attached.

Suddenly, the patient started hemorrhaging and his blood pressure started to drop, sparking a “chaotic” situation.

As the patient’s condition became critical shortly before 1pm, the substitute nurse tried desperately to reach the lunching anesthetist, but to no avail.

When the doctor and the primary nurse anesthetist returned to the operating room, they discovered that the patient’s respirator had been turned off, leaving him without oxygen for approximately eight minutes.

Despite immediately starting resuscitation efforts, doctors were unable to revive the man, who had suffered irreparable brain damage and died several weeks later.

The man’s daughter subsequently reported the incident to the health board, which on Tuesday issued a harsh critique of the hospital’s procedures.

“The operational planning, which allowed for the responsible doctor and nurse to take lunch breaks at the same time without any other doctor taking responsibility for the patient, entails taking an unacceptable risk,” the agency wrote in its findings.

The agency also found fault with the fact that the doctor wasn’t reachable by phone, as well as with the decision to hand responsibility for a high-risk patient with a single nurse who lacked sufficient knowledge of the equipment in use during the operation.

“The National Board of Health and Welfare finds, however, that the operation’s lack of organization as well as the chaotic situation which occurred was the underlying causes behind the misjudgments and insufficient care,” the agency wrote.