Good for you!

I'm sputtering! Mostly because I have difficulty deciding where to begin.
First, you describe the rebates as bribes, then you go on to say that you were able to get the court to grant you a portion of the bribes. What kind of practice is it that prescribes certain drugs in order for the physician to receive "bonuses" at the end of the year? How is not a conflict of interest?
Second, the antitrust rulings that prevent physicians from banding together to fix their fees do not prevent physicians form banding together to discuss and recognize the dangers of signing onto contracts with any group, whether it be an insurance company, a physician group, of the government.
Third, are your patients better off now that you have a physician group that fights for themselves? Wouldn't your patients have better access for a lower fee if they did not have to pay for the IPA administration, follow a formulary, and get permission to receive specialty and hospital care? How about a simple doctor-patient relationship without any third parties?
Fourth, don't get caught up in the concept of division of physicians that you decry by complaining about the differences in payment for the different services.
Incidentally, I thought your post about Martin Luther was very good.

Let me respond:
First off, the whole problem was that the insurance company was lying to us about the plan taking a loss. They were actually doing quite well (once we looked into their books). None of us thought the practice of rebates was at all ethical, but we did think it was strange that they would think we had no right to see their profits from it.
Second - we don't fix our fees. This is called a messenger model - meaning we have a single negotiator who deals with us all separately. It seems strange to me that doctors would potentially fix prices while muffler shops don't. The whole antitrust argument is a different post altogether, but many of the problems in healthcare owe to the hidden nature of costs. Calls for "transparency" in pricing of healthcare are squashed by Stark laws.
Third - Yes. If we did not have this recourse, we would have no way to balance the power of the insurers. PCP's would simply go out of business or drop insurance altogether. The purpose of the third party (that is paid for entirely by the physicians, by the way), is to advocate for the physicians. Unchecked, the insurance industry will do nothing but raise cost. They are not healthcare providers. Their job is to profit off of healthcare.
Fourth - Please note that this post focused on PCP's. Cardiologists and procedural physicians have hospitals to advocate for them. PCP's have nobody but themselves.

Medicine is a business. I can't take care of anybody if I can't meet operating expenses. This is the whole issue of primary care and why any small movements to reduce payment would end up destroying primary care.

Thanks on the ML compliment.

So, You Want To Be A Doctor…..

In recent times, others have said and appear to express concern about the apparent shortage of primary care doctors in particular- both now and in the speculated future. Typically, the main reason believed and speculated by others for this decline of this health care profession specialty that historically has been the apex of our health care system is lack of pay of this specialty when compared with other specialties chosen by potential physicians while in training, as it has been reported that PCPs, along with Pediatricians, have an annual salary below 150 thousand dollars a year often.

Viewed as one with great esteem and respect historically, a career as a PCP doctor may not be desired as a vocation by many that demands such admirable commitment and dedication, as reflected in their training regimen in the U.S. that consumes about a third of their lifespan. Such reasons for this paradigm shift may include:

Primary Care Doctors perhaps more than other physician specialties, seem to be choosing to practice medicine under the direction and financial security of one of the many and newly created health care systems in the United States. These regional and nationally created systems are typically composed of numerous hospitals and clinics under combined ownership- frequently of a profitable nature that is not dependent upon their beliefs as it is perhaps on their organizational motives and intentions. Yet their approach and etiology of their views regarding the restoration of the health of others are usually similar with such mergers of multiple medical facilities.

This monopolizing business model of these health care systems of increasing popularity is not necessarily a desired method to practice medicine as a primary care physician. Often, these systems employ their powers by limiting as well as dictating how their health care providers practice medicine. This is further aggravated by possible and clearly unreasonable expectations of their health care system employer, such as mandating that doctors they employ are required to see as many patients as they can in a day, and there have been cases of physicians being fired by a health care system. Conversely, there are instances where health care providers receive financial rewards for seeing more patients a day than what is determined as average visits by the organization. Such requirements likely and potentially affect or alter the clinical judgment determined by physicians employed in what may be viewed as rather authoritarian employers that potentially limit the medical care their employees provide to their patients, and the quality of this care.

Also, such health care systems may have their own managed health care sub-organization which may be determined by factors not in the best interest of the patients of doctors employed by the health care system to ‘control costs’.

The primary etiology and stimulus for a doctor to practice medicine in this way is due to their frequent inability to provide and employ ancillary staff in a private practice setting. This is also combined with the increasing premiums for their mandatory malpractice insurance, which may make doctors financially unable to work independently.

Malpractice laws and premiums, which are determined in large part on a state level, are an issue with those required to have this adverse aspect of their professions. Also, these premiums become more expensive for doctors as it relates to their chosen specialty as a health care provider. For example, the premiums of an OB/GYN doctor are usually higher than one of a specialty viewed less risky for lawsuits, such as Dermatology, perhaps. With malpractice cases that are initiated, plantiffs win about 25 percent of the time on average a half a million dollars. 95 percent of these cases are settled out of court, it has been said.

In addition, the issue of medical malpractice is also frequently a catalyst for a doctor to practice what has been called defensive medicine. This basically means that the health care provider is prohibited from relying upon their subjective factors in their assessment of their patients, which in itself raises the question of what the point was of all of their training in the first place. Because if a doctor practices medicine in such a way with defensive medicine, it typically involves what may be considered as unnecessary diagnostic testing for their patients to rule out what may be unlikely disease states of their patients’ medical conditions. This waste of medical resources is further validated by the legality reflected in the tone of the notes a doctor usually annotates or dictates with their patients. So one could speculate that over-treatment is as common as under-treatment of patients in today’s health care system.

Such restrictions and limitations imposed on today’s primary health care provider are usually not fully illustrated during their training for this profession, which is one that has been viewed as one that is quite noble and of great responsibility on a societal level. This may be why this medical profession may no longer be viewed as distinct from other vocations as it once was. In large part, it seems that presently the profession of a doctor has been reduced to one dependent on the financial stability and growth of its employer, which may alter how the doctors perceive what is expected of them as well, which may affect the importance of how they view their profession, as it has been said that overall, doctors are somewhat understandably more cynical and demoralized, which may be replacing the pride they historically have viewed their callings as doctors, as well as the perceptions of patients in the U.S. Health Care System.

Further complicating and vexing to these restrictions is the usual financial state of the individual physician, as they normally have to pay off the debt acquired from attending medical school and training, which averages well over 100,000 dollars today after their training is completed, it has been estimated, along with this debt amount presently is about 5 times higher than it was only a few decades ago.

Conversely, there are some who believe that doctors in the U.S. are over-paid and are compared with some corporate monster, who behaves based upon the premise of greed. In spite of how they are judged, physicians are likely not absent of financial concerns as with many others- which may be of more of an issue than many other professions, comparatively speaking, in addition of taking on more responsibility that is of greater importance compared with other vocations. Such realistic variables should be factored in when one chooses to judge the profession of a physician. On the other hand, no physician should view their jobs as no different from any other venture capitalist when rationalizing their income and motives related to this exceptional vocation as a physician, as others are more dependent on their judgment.

It has been determined by others, and suggested often and lately, that many of today’s physicians practicing medicine in the United State do not recommend or speak favorably of their professions compared with their typical views of their profession in the not so distant past. While this self-perception physicians may have of a negative nature may be somewhat understandable it is also and potentially unfortunate for the health of the public in the future, and the nature normally associated with the medical profession which could deter ideal medical care for others.

There have been cases where doctors do in fact change careers, and get into vocational fields such as medical communications or corporate medical companies. Also, expert witnessing is another consideration for those who choose to leave their profession. Finally, other choices considered include consulting and research. The training of doctors fortunately leaves them with options not involved directly with the flaws of medical care, but this is bad for us as citizens, overall. The etiology of their departure from their designed profession is largely due to the negative state perceived by themselves as well as others of their profession as medical doctors.

Then again, not all doctors are deities. Like others, some are greedy and corrupt, which complicates others in this profession in relation to how their vocation is viewed by others and based on limited judgment and analysis. Yet citizens overall should determine what sort of health care they desire, and it seems that often they fail to voice this right as a citizen.

For perhaps Primary Care Physicians in particular, the medical profession and those who provide medical care clearly needed by others to some degree appears to be absent as a desired path of today’s careerist if it is sensed that doctors are uderstandably a bit demoralized these days. The authentic reasons for what many believe to be a negative perception of possibly the entire health care system may never be known, yet many would agree that most U.S. citizens are understandably concerned with the state of this system of great importance to society. Yet the public needs to be more active more in assuring this necessity is more aseptic.

“In nothing do men more nearly approach the Gods then in giving health to men.” --- Cicero

Dan Abshear (ex-military medic and physician assistant for nearly 20 years)

Author’s note: What has been written has been based upon information and belief of a layperson, yet also the assessments of a patient.