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Bankrupt Healthcare
The Decline of the Indy Doctor, the Rise of Costs
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  • qet

    Weberian rationalization claims another victim.

  • Michael Bogdasarian

    The more critical element is that hospitals often pay more to physicians than is generated simply from visits. The difference hopefully for those institutions employing physicians is in income from tests and procedures done at the facility. The link of physician pay to office practice also drives the limitations on time spent, which often means more tests are required to make up for the lack of personal involvement. Electronic medical records present another difficulty. While theoretically allowing a more seamless transfer of patient information from an office to another, or to the hospital, there is a real tendency for the hospitalist not to update information. To maximize revenue by increasing the scale of “service delivered”, it is easy to copy and paste the physician’s record into the hospital record without actually doing the work. Since the hospitalist must make a revenue target to insure his salary, and since the patient burden is fairly high, the tendency is to “be more efficient” without actually obtaining updated information from the patient. We all know that performing a comprehensive history and physical exam is time consuming, and with “time cards” now a real part of physician activity, one can hardly fault either the physician or the hospitalist (not to denigrate but to distinguish the two) for skipping parts.

    • Andrew Allison

      I think you’ve hit the proverbial nail on the head — unlike a private practice physician, one employed by a hospital gets a cut of the test and procedure revenue. Might this explain, by way of more unnecessary tests and procedures, the fact that costs are higher for for hospital-based services?

      • DocEpador

        Nope, that’s illegal anyways. But the employee thinks they are only going to have to worked fixed hours without administrative burdens. Hah! Once you find you have to see 30-40 patients in the time you used to see 20, use a new EMR that is less efficient than your old charts, and you have to stay up late finishing charts, but since you are salaried… The private docs that sell out to the hospitals almost all find out they have been screwed and give up after a year or two. The new docs don’t know any better, but they also don’t know how to give better care. So we all are screwed.

  • Jacksonian_Libertarian

    Whenever competition declines, the Quality declines, the Service declines, and the Price rises. It’s the “Feedback of Competition” that forces continuous improvements in Quality, Service, and Price in free markets. Only by making everything except Catastrophic health insurance paid for by the individual illegal, can healthcare become better.

    • Andrew Allison

      As you remind us, on an all too frequent [/grin] basis, competition is key to improvement in price/performance. You are also correct that high-deductible plans have a salutary effect on healthcare costs. I fear, however, that you are wrong about how to make healthcare better. If there’s no alternative to catastrophic health insurance (as is the case with ACA), there’s limited competition. As evidence of this, I offer the miniscule differences between the premia for the same coverage quoted on the ACA exchanges. More importantly, that wish you wish for is not going to happen; the best that we can hope for is that the employer mandate will be implemented for all employers and 100% of employer-provided insurance premia will be treated as income to the employee.

  • MarkE

    Doctors who are employed by hospitals are paid up to twice
    as much for the same service provided by a private physician in his own office.
    This is, of course, encouraging doctors to sign up for hospital or other
    institutional employment at an even more rapid rate. Eventually, the rates for
    both will be cut by the same percent, driving all private doctors, who make a
    living from insurance payments, into bankruptcy.

    • DocEpador

      The patient is charged twice as much is not the same as the doctor getting paid twice as much, believe me.

      • MarkE

        True, but the hospitals can pay more for the time being.

  • FriendlyGoat

    Well, yeah. Doctors telling hospitals what to do are better than a trend toward hospital administrators telling doctors what to do. Now that TAI has discovered that wisdom, when are you guys going to get off dead center and propose something useful? Nothing is going on here but support for the GOP which plans to do exactly nothing except shift costs from corporations to individuals.

  • Louis Thorndon

    The Left does not care. They want to take a key element of the bourgeoisie into the Left and getting doctors to lose their independent practices is the way to do it.

  • TMLutas

    We’re saving our pennies for the day when the local hospitals reverse direction and hold a fire sale on the practices they unwisely are acquiring at the moment.

    Honestly, the hospitals would do better to go to McDonalds and the rest of the franchise giants to get advice on how to run a franchise operation and have the practices run on that model.

  • forester

    Hospitals might or might not buy quality when they buy physician groups but when their hires are low quality it doesn’t hurt them as quickly or as much as it does the private group. Administrators don’t personally go broke or to court if they hire butchers. This is happening at a previously first rate hospital I am familiar with- one has to be in the know to avoid the butcher!

  • Dantes

    The government seeks to drive doctors into employment because it is easier to control 5500 hospital CEO’s rather than hundreds of thousands of physicians. The first purpose of the electronic medical record is for billing…hospitals can use it to maximize reimbursement by “code farming”, that is, assigning the most profitable code numbers describing illness to a patient to maximize payment to the hospital, whether or not those numbers actual increase the cost of care. The second purpose of the EHR is to institute so called quality care protocols, which increasingly will utilize IBM Watson computer intelligence to outline a diagnostic and treatment strategy based on population guidelines.

    Even now these are being implemented. In the not to distant future, straying from the computer allowed diagnosis and treatment plan will be a black mark on a doctors…or providers…record. These protocols are why the government is keen to turn people unqualified to practice medicine by their lack of training from physician extenders into physician replacements. They don’t know enough when to disregard the protocols. So, if your disease has read the protocols you might be ok, but if not, good luck. But if the government saves money, it’s all ok in the end. Except,maybe, for you.

    • MarkE

      Naïve physician replacements and less conscientious
      physicians who see themselves as hospital or system employees could…oops…put a
      quick end to fragile patients with expensive diseases. Also, who is programming
      Watson? If the “death panel” has any input Watson’s recommendations might be
      miserly for those over the age of 70 or 80.

    • DocEpador

      Umm, that is now, or maybe yesterday, not the future.

  • DocEpador

    see my original comments at InstaPundit

    Interestingly, I recently set up a new private practice with the help of a loan from the local for-profit hospital that’s only payback stipulation is to stay in practice for 4 years. The hospital gets another provider in the community, I run my own practice, and I can afford the entire time period on the loan amount and the paltry income I am getting on Medicare and Medicaid patients. No strings – I can refer pts anywhere. I am not an employee [which is what I thought I would be when I came to this community] and I am in a solo private practice, which I swore in 1997 I would never do again after 15 years. So all is not doom and gloom, at least until the loan money runs out in four years. ‘Course I can afford this since I have very little budgetary needs, no loans/mortgages and only one ex to support. If I was just out of med school/residency, it would never happen.

    Then there is this side of the situation:

    The local hospitalists and ER docs think I’m crazy and very annoying ’cause I want to be called and involved if my patients show up in their care. They’d prefer just to send me a fax of records after patient discharged. Even say they are too busy to call the primary care doc to find out what the real story is on a problem patient (but fill chart with notes about how difficult it is to treat patient since they can’t get a hold of family, but they don’t call me or return my calls or notes). I guess I am just too old fashioned, and as a commentor above noted, way too conservative and anti-progressive/enabling for these liberal, progressive, enabling employee providers. Even having to fight some SJW-type issues with them. Arrgh.


    Also factor is that about 10 years after MCare, Feds cut Med School $$, so that starting Fall 1976 tuition rose 200% and then doubled again. I got out of Med School having paid less than $10k for tuition in 4 years. The folks that finished after me all had big debt burdens, and by 1980 they had matured to a level that changed the face of US Medical Practice forever.

  • bittman

    The decline of small doctor practices was a given under Obamacare which made it too expensive for them to stay in business. Working for hospitals makes hospitals responsible for keeping the electronic medical systems up to date and for complying with all of the Government’s Obamacare rules and regulations. EVERYONE WHO HAS PAID FOR A HOSPITAL ASPIRIN KNOWS THAT HOSPITALS CHARGE MUCH HIGHER PRICES THAN THE PRIVATE DOCTORS. Obamacare needs to be repealed. The middle-class (the people who are paying the Obamacare bill for the entire country) simply CANNOT afford Obamacare.

  • teapartydoc

    Once again: The only way you will ever see medical care delivered at competitive pricing is after the cartel is broken up. ABOLISH MEDICAL LICENSING. Right after taking 501c3 status away from the NFL, and removing government mandated monopoly protections from Major League Baseball.

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