Shawn Whatley is past-president of the Ontario Medical Association. He has worked in emergency medicine, as a coroner, in a vein clinic, and as a surgical assistant. He also held a leadership role at a large suburban hospital. He now practises family medicine in rural Ontario. Visit his blog at shawnwhatley.com.in rural Ontario. Visit his blog at shawnwhatley.com.
The Nutty
Hospitals lose money for seeing more patients; doctors earn more for seeing more patients
Unlimited sick days for some nurses
March madness: hospitals spend like crazy before year-end or lose funding for next year
Pharmacists paid more for same service than MDs (e.g. flu shot)
Black market in radiology and lab licenses
NPs and midwives earn more per patient than MDs
Labs have fixed budgets: more tests means less profit per test
Bigger Issues
Single payer healthcare also raises other, more challenging problems:
Those who know cannot speak. The system suppresses dissent. People cannot speak up, because they have nowhere else to work. Professionals working in hospitals or academia must stay quiet. Single-payer systems give tremendous power to administrators who run the monopoly. It enriches and expands government. Price controls appear to limit costs, but profits are found in other ways. For example, price controls force doctors to shorten visits, unbundle care, up-code, or stop providing a service. Centrally planned single-payer systems function on Hayek’s Fatal Conceit, the assumption that planning is possible:
The curious task of economics is to demonstrate to men how little they really know about what they imagine they can design.
Local knowledge is impossible to capture or to use in managing the system. Single-payer systems incentivize collusion with government to exclude competition. It creates a psychological change in Canadians. Whereas choice empowers patients, single-payer fosters dependency on the system. It creates increased demand for fixed price services but decreased availability of those services. Single-payer assumes that bigger is always better. But bigger often becomes too big to manage. A CEO of A.T.&T. once said, “A.T.&T. is so big that, if you gave it a kick in the behind today, it would be two years before the head said ‘ouch.’”
Dr. Goodman’s article is a fantastic foray into the dark history organized medicine, culminating with a brutally honest assessment of the cartel that resulted. He gives a great preview of the good stuff in Greg Scandlen’s new book, Myth Busters: Why Health Reform Always Goes Awry, summarizing the oft-repeated myths we hear about healthcare economics thrown around like dogma.
Primary care panel sizes are an important component of primary care practices. Determining the appropriate panel size has implications for patient access, physician workload, and care comprehensiveness and will have an impact on quality of care. An often quoted standard panel size is 2500. However, this number seems to arise in the literature anecdotally, without a basis in research. Subsequently, multiple studies observed that a panel size of 2500 is not feasible because of time constraints and results in incomplete preventive care and health care screening services. In this article we review the origins of a panel size of 2500, review the subsequent work examining this number and effectively debunking it as a feasible panel size, and discuss the importance of primary care physicians setting an appropriate panel size.
Recent studies of various practice settings in the United States and abroad found current panel sizes ranging from 1200 to 1900 patients per physician. For example, Kaiser Permanente reported a mean per-physician panel size of 1751 patients, and Group Health Cooperative of Puget Sound reported a panel size of 1490 patients per physician.18 The US Department of Veterans Affairs reported a mean panel size of 1266 patients per full-time equivalent physician.1
As a seasoned advocate and DPC practitioner, Dr. Brian Forrest knows all to well the problems that misinformation can create for a movement built almost entirely on word of mouth. In the second installment of our ongoing series, Dr. Forrest provides a healthy dose of reality and debunks the nine most dangerous myths about DPC.
For the sake of brevity, I am not going to show my math. Trust me, I’m a doctor! Here are the average panel sizes based on the assumptions above using 2012 census data.
FP/GP = 1,041 patients per doc
IM/IM-Peds = 464 patients per doc
Pediatrics = 552 patients per doc
Ob-Gyn = 642 patients per doc
Geriatrics = 1,237 patients per doc (this was tough to estimate, maybe way off)
Take a close look at the patient panel sizes. Yes, they are derived from raw data and don’t represent actual practices, but they do represent every single individual via census data that were represented in the categories that I used. Why are they so much lower than the “average” U.S. primary care doctor patient panel numbers we see quoted so often? The panel sizes would be larger if we count those with more than one doctor, but that would be a wild guess. But, that effect is dwarfed by the fact that I assumed every single American in the age/gender categories that I used has a personal physician, which we know is not the case. There is the issue of uneven distribution of doctors, with more in urban/suburban area compared to rural areas, tending to skew sampling surveys to higher panel sizes. The other sampling bias of surveys may be web presence of the practice. Again, these practices are easier to locate and contact; which might also account for why they have larger patient populations.
So it the physician shortage real? I don’t know. I do know access to supply is out of balance and we can do much better with some efficiency enhancers.
The idea is deceptively simple: Pay frontline doctors a fixed monthly fee directly instead of through the byzantine insurance bureaucracy. Make the patient, rather than the paperwork, the focus of the doctor’s day. The result will be happier doctors, healthier patients and a striking reduction in wasted expense.
“Those who cannot remember the past are condemned to repeat it,” declared philosopher George Santayana. The U.S. “health care cost crisis” didn’t start until 1965. The government increased demand with the passage of Medicare and Medicaid while restricting the supply of doctors and hospitals. Health care prices responded at twice the rate of inflation (Figure 1). Now, the U.S. is repeating the same mistakes with the unveiling of Obamacare (a.k.a. “Medicare and Medicaid for the middle class”).
Figure 1: An Indexed Comparison of Health Care Inflation and Consumer Price Index in US from 1935 to 2009 (Source: US Census 2013) Nobel Prize-winning economist Milton Friedman wrote that medical price inflation since 1965 has been caused by the rising demand for health-care coupled with restricted supply (Friedman 1992).
Coding was one of the earliest manifestations of the cancer consuming the medical profession, but the disease is much more broad-based and systemic. The root of the problem is that patients are not payers. Through myriad tax and regulatory policies adopted on the federal and state level, the system rarely sees a direct interaction between a consumer and a provider of a health care good or service. Instead, a third party—either a private insurance company or a government payer, such as Medicare or Medicaid—covers almost all the costs. According to the National Center for Policy Analysis, on average, the consumer pays only 12 percent of the total health care bill directly out of pocket. There is no incentive, through a market system with transparent prices, for either the provider or the consumer to be cost-effective.
As the third party payment system led health care costs to escalate, the people footing the bill have attempted to rein in costs with yet more command-and-control solutions. In the 1990s, private insurance carriers did this through a form of health plan called a health maintenance organization, or HMO. Strict oversight, rationing, and practice protocols were imposed on both physicians and patients. Both groups protested loudly. Eventually, most of these top-down regulations were set aside, and many HMOs were watered down into little more than expensive prepaid health plans.
Our Rights come from God, not government. Physician/ Patient/ Survivor/ Wife/ Mother of 4 daughters/ Small biz owner/ Limited Government/ No Socialized Medicine/ Texan/ President www.AAPSonline.org
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As the third party payment system led health care costs to escalate, the people footing the bill have attempted to rein in costs with yet more command-and-control solutions. In the 1990s, private insurance carriers did this through a form of health plan called a health maintenance organization, or HMO. Strict oversight, rationing, and practice protocols were imposed on both physicians and patients. Both groups protested loudly. Eventually, most of these top-down regulations were set aside, and many HMOs were watered down into little more than expensive prepaid health plans.