A Doctor Speaks OutHe's Mad As Hell and Won't Take It Anymore.

This comes from an internist. He has had a primary care practice in the New York metropolitan area for more than 20 years. For obvious reasons, he asks to remain anonymous. I've met him and can vouch for his identity.

Right now, I have dropped my participation in every insurance plan except Medicare. I can tell you from first-hand experience that the private managed care plans are out of control with their denials, pre-authorization requirements, and drug formulary restrictions. Plain old Medicare is the last bastion of health care insurance that actually allows the doctor to make a decision on what a patient needs without having to fill out reams of paperwork or spend endless amounts of time on hold, waiting for insurance company representatives who barely have a high school education to tell me if I can provide needed procedures or specialist referrals for patients they've never laid a hand on.

Has anyone looked at the expenses of a primary care physician's practice vs. the ridiculous insurance company reimbursement schedules for E&M (evaluation and management) services? That is, for actually talking to and caring for patients instead of cutting and irradiating them? My average reimbursement for a 15-minute office visit by a patient covered by a private managed care plan is about $50 vs. Medicare's $70. Too bad it currently costs me $92 to provide that same service. And can anyone explain to me why I have to pay $50,000 in salary and benefits for someone in my office to sit on a phone all day long fighting for my patients' health care needs? Especially when I'm attempting to authorize procedures I believe necessary that I will not earn a penny on? At the same time, radiologists and other overpaid subspecialists get to bill hundreds of thousands of dollars a year on the procedures I have to fight to authorize for them?

Or maybe someone would like to explain the insurance companies' wonderful new managed care formulary departments, which approve medication authorizaation requests -- or don't. Three times in the last two months they have rejected my requests for more "expensive" diabetic medications, invoking the requirements that all diabetics be given generic Metformin as a first-line agent. Unfortunately, these patients all happen to have weakened kidneys (common for diabetics) and would get lactic acidosis if I prescribed Metformin. It would likely kill them! But I guess dead patients cost the insurance companies less money than living ones. And I guarantee that some busy primary care physician's office will get one of these form letters and blindly sign it without taking the time to check the patient's renal function numbers ... but of course only the physician can be sued for a mistake like this, not the insurance company.

How about the patient I'm trying to treat with Symlin, a new diabetic drug specifically for Type II diabetics already on maximal treatment (including insulin) who are not reaching the goal of controlling their hemoglobin A1C levels? The formulary morons rejected my request for authorization based on the fact that my patient's sugar numbers were -- get this - too high! I've tried for three weeks to get the insurance company physician who denied the authorization on the phone, but he's never in the office; and every time I'm told he'll call me back within 24 hours, he never does. I've reported this to the Commissioner of the New York State Insurance Department, but the case could take months. Meanwhile, this poor patient is suffering a slow death from her uncontrolled disease.

Yet all I see in the press is how it's the greedy doctors -- broad brushed as an undifferentiated class -- who are driving up costs of health care. Take a look at the disgusting piece printed by The New York Times earlier this month, headlined Survey Finds High Fees Common in Medical Care, about doctors charging exorbitant rates for out-of-network care. Guess who provided the survey data? American Health Insurance Plans, a lobbying group for the insurance companies! ("The health insurers, saying they felt unfairly vilified, gave the report to The New York Times ... explaining that they wanted to show that doctors' fees are part of the health care problem.") I bet they and the Times reporter had to dig down pretty deep to find what amounts to 0.0000001% of the problem with the current system.

I can tell you for a fact that in the past 20 years, my reimbursement rates have dropped to about 30% of what they were in 1988, while my costs have at least tripled. My income has steadily declined every year over the past 10 years. It's now down to about half of what it was during my peak earning days. Meanwhile, the CEOs of the health insurance companies are making $10 million and more a year, with lord knows how much in deferred compensation and stock options. The CEO of United Healthcare walked away two years ago with $1.5 billion in compensation over his last five years running the company. Imagine how much care you could provide with a fraction of that money?

And so I am currently working on my exit strategy, as are many of my friends in primary care medicine. And if you think there are younger people eager to fill my spot ... think again! With an average of $300,000 in student loans, eight years of college and medical school, and four years of indentured servitude at minimum wage as a resident physician in a hospital, these poor fools will be starting out on their own at age 30 and often older in a job that might earn them $100,000 a year ... and that's if they're lucky.

Yes the system is badly broken, but not by my primary care colleagues. It's broken by the greed of the insurance and pharmaceutical giants who have sucked every dollar out of the system, and by the politicians who are in bed with their lobbyists, take their money, and do their bidding. So enjoy your new health care system. Nurse practitioners and foreign medical school graduates will be your new primary care providers managing 95% of your needs. I hope you don't come down with something serious that would actually require someone with knowledge and experience, to say nothing of the training ... as my friends and I will all be long gone.

You can sign me:
20 Years of Primary Care Practice and Totally Fed Up ...

Done.

Comments

[meryta]

Congratulations for an honest, clear personal account backed up by evidence. I favour those who 'make' over those who 'market'' and a fair rate of pay is reasonable whether one is a plumber, medic or manager.

I am sure there would be many who could serve as parts of a good locally controlled single payer system without wanting kickbacks and graft.

It is time to support http://www.madashelldoctors.com/ as they go to Washington on the American people's behalf for 'single payer'. Who says doctors, plumbers and managers must be corrupt or inept without the hand of a centralised agency [corporate or federal] behnd them. We all can benefit from a 'fair' rate.

Why do I always think of Elizabeth Warren when I think of a decent person serving with generosity? I really liked it when some media nincompoop tapped her for the senate & she said 'I already have a job'. She teaches.

To teach/care/plumb/manage as service is a lesson we all can learn. Thanks for yr input Dr D.

[JTyroler]

This doctor should be applauded for speaking out - a lot of supporters of private insurance companies and the status quo fail to realize that greed is the one factor that has caused our health care industries to have the best technology, most research, etc. and make it unavailable for most Americans.

[Leakman]

If you truly believe that you are working selflessly and everyone else is the blame. Why don't you put your name to it. Get together with a group of other doctors; form a cooperative, where everyone pays cash for regular office visits, minor blood work, x-rays and diagnostic tests. How come it only costs $98 for an MRI in Japan? Most people have a high deductible anyhow; between $2000 and $5000, along with their premiums, they shell shell out over $10,000 a year, before they get one dollar paid by insurance. Sale memberships(partnership) to buy into these cooperatives. Look health is not insurable. People get sick and sometimes they bring it on themselves. Spending time with patients is probably more important to prevent things getting out of hand. Its everyones fault that we spend over 1.5 to 2.5 trillion dollars a year on healthcare and we are ranked 37th in the world.

[dr d]

I don't put my name on this post as I still have a practice to run and patients to care for... that is until I can complete my plans to get out of this quagmire called modern medicine. Not to worry as I have partners who I trust will be assuming their care.

Unfortunately most physicians have spent their entire lives working towards a single goal... becoming a healer and building a practice. I've been fortunate to have developed a niche that will allow me to bring my medical expertise to many who need it greatly. Hopefully they will see the value in my services and actually be willing to pay for the expertise that I offer. Quite a different scenario from the average doctors office where the visit is virtually free ($10 copay) and therefore carrys virtually no value to the patient. Unlike fighing some nameless, faceless insurance representative to justify care and recover what ends up being about 30 cents on the dollar.

As for a cooperative as you describe... been there, done that! We set up a $99 monthly fee for all uninsured (or underinsured as in high deducible) patients covering everything we offer in our office, including all primary care visits, routine vaccines, EKG's, bone density analysis, echocardiograms, vascular testing... you name it. Unfortunately a colleage of mine who set up a similar system was brought up on charges of running an insurance company without a license, and was shut down by the state. Go figure!

[AynSpandex]

How anyone who truly cares for the health of the patients under their care can survive in the current system, reverse engineered as job security for pharmaceuticals and in$urance companies, is a mystery to me. The internist mentioned (a dying breed in today's climate) is to be congratulated for trying to stick with it so far. We meet heroes every day...