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Thursday, October 15, 2009

Real Reform Must Come From Within The Profession

Real reform is never going to come from Washington. It has to come from us.
When Obama talks about "keeping what works and making it better and getting rid of what doesn't work", he is really talking about remodeling a house with a fundamentally flawed foundation and doing nothing about fixing the unstable foundation.

That unstable foundation is the third party payer system--as long as we have a system in which a third party is paying for an individual's needs regardless of the commodity and regardless if it is government or privately sponsored, there will always be excesses in terms of waste, greed, and inefficiency at all levels of the system, including the payer, the provider of the service or product, and the consumer. As long as there is the perception that someone else is paying for “it”, human nature dictates that we all will want the best while the payer will do everything possible to provide us with something less.
We as physicians need to recognize that we are speaking about fixing a broken system that we are part of and that we are partly responsible for.

No one may want to hear this--especially the specialists but the fact of the matter is that over 90% of all medical care --which does not require high tech or the "latest and the greatest"--in this country can be delivered inexpensively and efficiently in private offices by primary care physicians. However, we are top heavy in this country with specialists and not enough primary care physicians. And, the majority of the primary care physicians are employed--and controlled--by the very system that we all deplore. On top of that, they prefer to work 9-5 and no weekends, take no call, have no admissions, do no hospital work and make as much money as an ophthalmologist doing 50 Lasik procedures a day!

I am in no way saying that primary care physicians don’t work hard or don’t deserve to make a lot of money, I am simply saying that before managed care and before doctors went to work for them, they worked a lot harder and for relatively less money than today. I do however, think that Lasik or LK is ridiculously overpriced!

When I worked in ERs after I retired from surgery, about 70-80% of what I saw did not need to be seen in the ER, especially after hours and on weekends--and, contrary to popular belief, they were not all indigents or uninsured with no place to go--many of them were insured with no other place to go. They had tried to call their doctor and were told to go to the ER or nearest urgent care! Most ambulatory care or urgent care centers are closed by 10pm and so, if the patients are sick—insurance or no insurance—they either wait it out and suffer at home—or they go to the ER and wait it out and suffer there!

So how do we affect reform? We do it by doing what we learned and what we did best in training. We all succeeded because we were trained and were able to work hard and thrive under adverse conditions. We all were able to use intelligence, experience, and ingenuity to get us through difficult situations—especially difficult patient management situations. We relied on each other—both within and outside our specialties—to accomplish a common goal. Of course we still do these things today; however, self-interest has changed how we do these things!

Reform has to begin with us. Plain and simple. We must retake what is rightfully ours—what we worked so hard and sacrificed much of our lives to attain—that is the responsibility of delivering medical care to society. We have abdicated that role which we had for over 2000 years to “big business” and we are dangerously close to having any remnant of that responsibility taken from us by the government.

We don’t need the government crafting and shoving down our throats ridiculous bills that no one can read and much less understand and that will cost us trillions of dollars—only to give us more of the same.

All we need the government to do is to craft legislation that will level the playing field between doctors, plaintiff’s attorneys, and the huge insurance companies. Then and only then can real and meaningful reform take place with physicians leading the way.
For this to happen however, will require real tort reform, which should include penalties for frivolous lawsuits, loser pays costs and damages, amortization over lifetime of awards, caps on awards, and limits on contingency fees.

To reverse the specialist to primary care ratio that exists today, the government (both state and federal) could offer loan repayment incentives, tax credits, and interest free or low interest loans for physicians--especially primary care docs to open practices. They would be protected from predatory and monopolistic practices by the insurance companies who should actually have nothing to do with them as most patients should be paying for their routine primary care out of pocket. They would negotiate and set prices through free market principles and could negotiate with patients and employers individually or through IPAs.

The states could also mandate that the insurance companies would have to pay "any willing provider" that the patient chooses to see.

The over abundance of specialists would work itself out through market forces...the better ones would succeed, some would retire, and others could change professions or practice primary care.
Insurance companies could be required to only cover uncertainty (as it was designed to do) and especially calamitous uncertainty, like a house fire or a car wreck or an MI or costly procedure(s). Routine visits, routine meds, and screening exams should be paid for out of pocket--giving the patient some responsibility in their care. Insurance companies could provide more coverage for routine care if they wished and patients could elect to buy such coverage, but it would be a traditional indemnity type policy where the patient pays out of pocket and gets reimbursed by the insurance company.

Specialists could continue to be employed by the hospitals or HMOs and/or concentrated in certain “centers of excellence” if they wished and the insurance companies would only be required to pay for this aspect of care--high cost, high-tech care and only if medically necessary. Not just because it is available or just because the patient and/or the media wants it.
True reform can happen and for it to happen it will require work and commitment on our part (which we know well)...which means being available to the patient and providing excellent service AND a quality product.

I am successful because I see people when and where they want me to see them. I see the patient that has insurance and tries to get in to see his PCP only to be told he can't get in or to go to the nearest ER or Urgent Care. And when I do see them, I see them with a smile on my face and I do everything I can within my power to not make them wait! If they have to wait more than a half hour to see me or any of my providers (which is extremely rare) we offer to discount their visit or give them a free visit. If they want to be seen in the middle of the night, I or my providers arrange to see them in our offices or in their home--just like the old days. I can often learn much more from seeing a patient in his or her own environment than I can by performing a 30 minute H&P in my office and without asking a single question. But that is not the point, the point is, that we have shifted care from a provider friendly venue to a patient friendly venue....and that takes extra work and commitment..but it is well worth it and our patients love it.

Today's patients want us to know that they are not just passive participants in their health care--they expect us to respect that their time and needs are just as important as ours.
We all know you can be the smartest and ‘best doctor in the world’, but if your service is bad , it doesn't matter much...and that goes for the office staff.

The old-timers called it the three As--affordable, affable, and available and it is just as applicable today as it was 50 years ago. Unfortunately, we have become anything but the 3As--although I have heard (and used) a few pejorative terms that start with A to describe some doctors (including myself) today.

We can affect reform, but it will not come from marching to Washington or writing letters to congress or closing our offices. It must come from within—within each of us and within the profession. It can be done.

John R. Vigil, MD, FACPE
CEO and Medical Director
Doctor On Call

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