$1,000 fine and jail time?  What are we coming to? 

If it were my kids giving this lady trouble, they’d be mowing that lady’s yard for a year (free of charge), and I’d consider letting her display the football in her window as a reminder to my kids that she is to be respected.

Gov. Linda Lingle’s administration cited budget shortfalls and other available health care options for eliminating funding for the program. A state official said families were dropping private coverage so their children would be eligible for the subsidized plan.

“People who were already able to afford health care began to stop paying for it so they could get it for free,” said Dr. Kenny Fink, the administrator for Med-QUEST at the Department of Human Services. “I don’t believe that was the intent of the program.”

and

The unique law allows caregivers to abandon babies and teenagers alike at hospitals without fear of prosecution. Originally intended to protect infants, it was expanded in a legislative compromise to protect any “child.” Some have interpreted that to mean anyone under 19.

are just two examples of unintended consequences of programs or laws that state governments have recently enacted to try and protect/provide for children.  I think that states have a tough job protecting and providing for children because the states lack control over the root cause - parents.  Providing for children is akin to trying to extinguish an oil well fire without being allowed to cap the oil well.  The most effective strategy might be education of school-age children.

Personal responsibility… how dare we suggest it!

“That doctor Dee, he doesn’t see drug reps anymore.  Well, he can take it and shove it up his ass!”

Says Dr. Dee to the pharmaceutical community - my lack of interaction with you should make your lives more pleasant, not less.  If withholding my direct questions - you know, the questions that if answered honestly point out the fact that most of you are trying to use me as your drug pusher to make your companies rich and fleece patients - and if my choice to avoid honest discussions arguments with you, that often leave me frustrated and you angry, drives you to imbibe and announce to an entire restaurant that Dr. Dee can place his desire to act honorably up his ass, then you only prove my suspicions to be true and strengthen my resolve to avoid you.  Bravo!

Who in their right mind would go through 11 years of schooling and training after high school to enter such a frustrating career?  Why go into 6-figure student debt to get underpaid and used as much as possible by as many people as possible? 

I’m cynical.

Perhaps admitting my emotional state is the first step toward healing. 

“Quit your belly aching and get another job you ungrateful, money-hungry doctor,” you say. 

Well, unfortunately for me, I enjoy primary care medicine.  I tried to convince myself to go into a higher paying specialty, but the thought of each and every other specialty either bored me or did not align with my priority of having a family-life.  I enjoy primary care.  I like the logic of preventive care.  I actually have compassion for people as well as an innate desire to reassure, diagnose, heal and advise patients.  I grew up without money.  I didn’t have health insurance until I entered medical school - and only then because it was required.

I’ve struggled, this first year of private practice, to reconcile my frustration with the system and my desire to practice medicine. 

I’ve read stories about primary care doctors in their 50’s wanting to leave practice because they’re tired of the bureaucracy. 

Well, I’ve got news for politicians and those people interested in having primary care doctors around for the looming baby-boomer retirement years… the primary care physicians who are in their first year(s) of practice are unhappy too.  In our current system, it will not take long for the few of us who have actually chosen to go into primary care, despite the RUC and pressure from attending physicians, to leave the profession.

While 14 healthcare executives make enough money to pay an army of primary care docs… while government pays for expensive emergency center visits instead of funding primary care services adequately… while politicians regulate medicine to the n’th degree and add layer upon layer of rules, paperwork and red tape to our profession (without holding themselves to the same standards), while Americans are not held accountable for personal decisions as simple as eating and exercising, while doctors are allowed to be targeted with frivolous lawsuits, our insane healthcare system is dying a slow, painful death.  We continue to rob third world countries of their doctors to fill the need for primary care in this country, and the majority of our best and brightest students now pursue careers outside of medicine. 

Cynical enough?  Too much, I’m sure.  As dark as it sounds, these concerns are the brain fodder that I struggle with daily.  Ignorance is bliss, but ignorance (at least about this topic) has long since abandoned me (thankyou medical bloggers).

Hopefully a little wisdom and maturity (over the next few years) will bring me peace.

It’s Not Our Fault by Dr. Rob.

More On Doctors vs. Lawyers by Dr. Wes

duh - money matters in specialty selection by DB

The RUC (RVS Update Committee) Ruckus by Dr. Reece

Primary Care: Time to Reboot by  Dr. Rich

Medicine is a business, and if you come out of training without your thinking cap on, you will get taken for a ride by the people who know the business of medicine.  If you come out of the starting gate thinking strategically, you can position yourself in a favorable market and hopefully avoid disappointment and burnout.

1. Interview your friends and find out who has a good reputation. This is especially helpful if you have a physician friend to query, because they often have a insider’s perspective.

2. Check online reviews of physicians in your area.

3. Check the physician’s licenses and credentialing online. Most state medical licensing boards have a website where you can check a physician’s credentials and see if they have any disciplinary action or judgements against them.

4. Make an appointment and go see the doctor.  This visit is necessary to see if you’re going to “click” with the doc and the staff.  Be honest with yourself in your review of your visit and make sure you don’t “settle.”

“Medicare should role into town once every two years with a silent auction to set rates. Providers bid on the CPT rate schedule for the next two years. The lowest CPT bid gets to set that CPT rate for all other providers within that regional district. But here’s the kicker. The winning provider gets a 25% bonus for that procedural code for ONE OF THOSE TWO YEARS, as a reward for coming in with the lowest bid.”

Happy’s suggested price-setting scheme pits doctor against doctor, and leaves all physicians in a region vulnerable to just one physician’s (group’s) business strategy.  In general, physicians are poor business people.  The majority of physicians in this bidding war would be at the mercy of the few who do have business sense.  

The winning (lowest) bidder gets a 25% bonus the first year, which is equal to a 12.5% bonus for two years.  What if just one physician (or physician group) decides to bid at 12.5% below overhead costs on all CPT codes.  The winning bidder would then be able to able to drive the other groups in the region into the hole by 12.5% per year.  One of the following results would likely occur:

• the losing group(s) are forced to move out of the region or face bankruptcy
• the losing group(s) are forced to stop providing needed services/procedures resulting in an even more severe shortage of healthcare services in a region
• the winning group is able to force a merger with one or more losing group in a ”hostile takeover” of sorts
• the losing group opts out of medicare/medicaid, sets higher prices and becomes the provider of choice for the white-collar and private-insurance patients and ends up making more money than the winning group.  If this happens, we’ll find physicians/groups in many areas actually wanting to be the losing bidder in the medicare lottery.

I think the need for competition between physicians is real, but that competition has to be fair.  Giving one group the chance to cannabalize the other groups is not fair.