Patrick To Doctors: I See Your Winks And Nods

Call me a muckraker, but I thought Gov. Deval Patrick sounded a bit peevish at one point today when he spoke to more than 200 doctors who’d come to the State House to lobby their legislators.

He’d just laid out his determination to proceed with the next, cost-containing stage of health care reform, despite the great complexity of the challenge. (He phrased it much as he did at Harvard recently – here’s that text.) Then he told the doctors that he saw them exchanging looks across their tables, “the furtive glances you’re casting, winks and nods. Let me tell you, we are going here, to integrate accountable care organizations, we are going there together.”

The video is above. He concludes:

“We have got to deliver on what is ultimately a values statement, and that is that health is a public good, and everyone in this commonwealth deserves access to adequate, cost-effective care.”

The Massachusetts Medical Society, which organized the doctors’ visit to the State House today, is arguing for a dozen main elements in Patrick’s proposed payment reform, as expressed in talking points that the society distributed to the visiting doctors today. They include:

-Physician directed authority: Physicians will make most of the clinical decisions under a new health care model, so it’s only logical that they are at the center of decision-making, both at the public policy level and the clinical level.
-One size will not fit all: One single payment model will not be successful in all types of practice setting. Many physician groups will have a great deal of difficulty making a transition, due to their geographic location, patient mix, specialty, technical and organizational readiness, and other factors.

There are 11 more, including what I would call the “carrots only” provision: “The incentives to transition to a new model must be predominantly positive.”

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  • sick patient

    To all the ranting doctors, thanks for caring.

    • Tom

      What’s the DSM-IV classification of your illness, sick patient? 

  • Phobang

    I agree with Ridinggirl.  I am a young new physician and  am looking for a way out of my “public good” handcuffs as soon as possible and the public and deal with their crappy care, as long as I am not involved.  Had I known this was the way things would go, I would not have gone to medical school.  Sacrificing my time and life were not worth it.  Let someone stupider do it.  That’s what I tell all pre-meds today.  I have managed to talk 5 people out of going down that path.  That is 5 lives saved.

    • Oinkdoc1

      I got through med school on a Public Health Scholarship, so I had to go back to the state I received it from for 4 years after completing my residency.   It was worth it to me, since they had paid my entire med school tuition and fees, so I was lucky enough to be entirely debt-free.  I was well-compensated during that 4 year period.  However, I dealt with MANY of the issues being discussed on this board: Medicaid under-reimbursmend, drug-abusing patients, very little sleep due to unreasonable call expectations.
      Here is what I decided after my “time was served”:  I contacted Christian Medical and Dental Association and looked for a new job.  I’m now working the most satisfying job ever!  The hours are perfect for me, and the organization is one that refuses to dispense narcotics or other controlled substances unless truly necessary.  We treat uninsured patients – those who have “fallen through the cracks”, and we accept no government support, surviving on the donations and grants of those who truly want to help people who need it.
      I’m just saying that worthwhile organizations are there for doctors who care! :)

  • Slh53041md

    Hey, Gov., integrate this: EXODUS.

  • Al Davis

    I would venture to guess that the knowing “winks and nods” the governor was referring to were between and among physicians who have come to the realization that practicing in Massachusetts is a losing proposition; his statements, and the direction he is taking the state, merely confirm that notion.

    Another comment mentioned the inevitable rationing which programs like MassCare impose on the population, but there is a much worse form of that particular injustice than simply witholding funds from pre-defined groups. What will the state do when there are simply no longer any doctors in practice? The mass media would have us believe that more nurses can make up for the relative shortage of physicians, but that theory will only get you so far. As the accelerating exodus of physicians from the state gathers momentum, those unfortunate patients with serious disease, not amenable to being “noctored” in the Wal-Mart pharmacy, will increasingly find themselves with nowhere to go.

  • DrMLS

    Like all good communists, he believes that doctors are his slaves to move around like pawns and spread “the public good.” Just like he likes to give gifts and entitlements to the so-called “less fortunate” (a.k.a won’t work for it) with other people’s hard-earned money, he thinks that doctors are just too happy to be his tools. He may coerce cash out of citizens through taxation (theft) but unlike paper-dollars doctors are human beings and someone’s services cannot be gifted to others by a 3rd party, unless of course you use force like Fidel Castro uses in Communist Cuba –and then boasts to the world that he sends “his” doctors all over to solve health crisis in the planet (as if he owned the doctors who are forced to leave their families behind and go anywhere they are sent at a moment’s notice).

    • Suhaas

      Kudos to the Fidel Castro of Massachussetts! 

  • Ridinggirl

    It is all so sad…..America is going down the road of the lowest common denominator in virtually every profession and endeavor. Dr. Moore is correct in his assessment, but who in their right mind would go through 4 years of college, 4 years of Medical School, and between 4 and 7 years of residency training, end up $300,000 in debt (or else have to join the military and be told where to live for another 5 to 10 years well into their 40′s), so that they can then be viewed as a public good??? Really.

    Well, society will end up with what it deserves…………..most “health care providers” will end up being PAs and Nurse practitioners. And while no disrespect is meant to those important health care workers, only the wealthy will be able to easily access well trained and non Medicare, non Medicaid accepting physicians. If you don’t have the cash, then you will only be able to see the physician extenders, and then wait for months to see the few physicians that remain.

    Americans do not have any concept of what it takes to produce experienced well trained physicians. And when we herald the countries in Europe that have strong socialized medicine systems, we completely ignore the fact that the most successful ones combine well paying private practise with a modest amount of socialized government paid programs which have significant rationing of all sorts of care. In addition, these countries have traditionally invested huge anounts of money in supporting medical students, so that they do not graduate in debt. In fact, when I studied in Germany, medical students werre ACTUALLY PAID A LIVING STIPEND that would cover their room and board, and even allow for many of them to start and support a family. Imagine that!!!!

    In other countries, like Canada and Great Britain, it is the patients who clearly suffer. Sure, you can get your appendix out, cast broken bones, and get routinue types of medical care. But if you require expensive ICU care, you had better be the right age and medical condition, because the ONLY way to provide for this care in a society that is determined to be fully socialized is to RATION this type of expensive care. No ifs, ands, or buts. I have seen Canadian physicians fly their family members to the US for medical treatment at full expense, because they knew their 65 year year old wife with a hip fracture might not survie the 10 month wait to have her hip repaired under national health care in Canada. Everyone who has not been under a rock knows of the many cases of cancer/brain tumours etc in Canada, where the husband or wife would fly thier loved one to the US because there was a several month wait fo the diagnostic MRI, then a several month wait to see the appropriate surgical specialist.

    When my generation of physicians dies out, you will have a new younger, less experienced generation of doctors who will be content to work as employees, and who will not have any incentive to buck the system for their patients. The really bright and motivated ones who were not born with silver spoons in their mouth will have decided to go into any one of another type of profession where they have not had to sacrifice most of their young adult lives for the good of others, and then be told that they are just another “public good” when they finally have accrued the necessary training and work experience.

    • CristobalDeLicia

       YOU LIE!

  • DoctorHackenbush

    Unfortunately, quality medical care has deteriorated generally speaking throughout the country for many reasons, but particularly in the quality of physician being produced. Before any semblance of “managed care” patients would be admitted to hospitals where interns and residents would be afforded some time to generated a differential diagnosis and justify their suspicions. Due to pressure to reduce length of stay, current doctors, again in general, will order a battery of tests or multiple consultants to tell them the problem as opposed to being able to deduce this themselves (Ah, the dying art of medicine). ER physicians would actually treat, but now the path of least resistance is to admit and reduce liability. Technology has also impacted quality of care, where one now needs a chest CT to confirm the obvious pneumonia noted on a routine plain film. Need I go one? You reap what you sow. Truly smart graduates are avoiding medicine because of the headaches associated with multiple requests for prior authorizations for what was once routine tests, as well as letters of appeal due to increased denial of standard of care therapy. You want to know why the cost of healthcare has risen? Just look at the logorithmic rise in the number of medical administrators compared to physicians over the past 10-15 yerars. Massachusetts should look north to Vermont where they are implementing universal healthcare similar to the Canadian format. Their current focus on the ACO model means just more money wasted on overhead and administrators.

    • enjoy your PAs

      Let’s not also forget the politicians, who, I believe, are actually considered public servants (cough cough), who all make a lot more money than most doctors. And that doesn’t even include the payoffs from groups like pharma and the insurance companies.

      Because physicians are not allowed a voice in how the system is run, the people that are (politicians and administrators) will continue to increase the pay and jobs for the middle men, aka, them, and decrease the reimbursement and job satisfaction for physicians.

      Unless and until physicians stand as a group and say, “NO MORE,” this will continue to worsen.

      What’s that you say? Physicians are not allowed to come together as a group to have say in what goes on with their profession?

      Oh, then I guess the only option is the one that is coming. No more physicians. Like teachers, the best and brightest will look elsewhere for their careers, where they are appreciated, reimbursed for their work commiserate with their level of training and debt taken to reach said level, and not simply considered a public right, regardless of whether or not those given the “right” have done anything at all to earn it.

      And if you think the exodus won’t happen, open your eyes. It already is. I have been out of medschool for only 6 years and many people that I graduated with are already leaving practice for non-practicing jobs.

      I will be following them soon.

      I sincerely hope that the governor of MA develops a significant illness, and the only physicians that will treat him are sub-standard, much like his short-sighted, inadequate, “leadership.”

      • TexasPedsDoc

        I’ve been out of medical school for under 4 years, and out of residency for under one year. I’m already looking for alternatives. Though I love treating patients as a pediatrician, dealing with parents who have an entitlement mentality, no respect for expertise or education, or who walk in with an Internet WedMD-derived differential that I have to slog through is getting worse and worse.

        Worse yet, the payors won’t pay for this stuff. I can bill “prolonged service” for dealing with this crap, filling out FMLA forms, and so on, but the fact of the matter is that it usually isn’t paid. Then it flags me for an audit by MedicAid or some other organization where they try to nail me for billing fraud.

        With ACOs coming and the subsequent death of private practice, I am going to be forced into leaving the profession or going to a cash-only or concierge practice.

        Guess what? The government didn’t give me a stipend while I was in school. They didn’t subsidize my medical school education. They charge me ridiculous license fees. They have ridiculous amounts of regulation and paperwork that I have to do to practice. And Medicaid pays me about 30% of what I bill.

        I read this week that the average practice spends about 40% of their collections on trying to make sure that they collect the other 60%. It’s insane.

        And these people who bring their kid in and then waste my time when I have to address why this antibiotic and not that antibiotic, or explain basic high school biology, or why I’m not ordering an MRI of the abdomen for diarrhea? If I don’t do it, they go and make the nurses’ lives hell, and complain to hospital administration, and it’s bad “customer service.” If I do, I’ll bill them, but I’ll never get paid for it. Why? Because these people are not going to pay for the thirty minutes of my time that they flushed down the toilet.

        Meanwhile, the kid that I stay with at the bedside for five hours? I get to bill what, 45 hours critical care time?

        People need a reality check.

        • jaded MD

          Completely agree with this! I feel especially inane for having done a residency and fellowship, enduring long hours (with no hour limits placed) and having to put up with rude attendings and nurses who felt empowered to let those they feel beneath them know they are in charge. Now that I have been practice for the last few years, the sense of entitlement has gone way up, where there is no longer any respect given for physicians or nurses; people think they should get anything they request, even if it is extremely unrealistic, just like they would in any other business situation. And don’t get me started on reimbursements from insurance and some self pay patients. All I have to say is “Thank you Medicare and the US Government for making the medical system in the US attrocious!” When the system has made it so the only people left to treat you are midlevels with semi-par training and more mistakes being made, then people are going to wish they had more physicians around.

      • Jemimah

        I have said for YEARS that if physicians would do as you say, stand together and refuse to “play” the insurance companies’ games, they would be doing themselves and their patients a huge favor.  This mess isn’t the fault of MD’s, but greedy insurers and overblown costs for medical school.  Perhaps the US should do as many European countries do and somehow subsidize medical education.  I wanted to be a doctor, and was starting out when “managed” care was just beginning to take over.  I looked around at all my friends who were doctors and saw how this was affecting them and ran.  Sometimes I still wish I’d gone ahead, because as a career, medicine can be very satisfying but the BUSINESS of medicine has become a nightmare.

  • M. Moore, MD, MPH

    The increase in the percentage of employed (and therefore, powerless) physicians and the decline of private practice now make this an inevitable course. Under this model, the institutions and administrators will drive the decision making process and determine reimbursement. ACO’s will make even the notion of private practice non-viable with the exception of cash services such as plastic surgery.

    As physicians, we face a financial path similar to those of commercial pilots over the past two decades…. find a pilot and have a chat with him or her…. or simply read what “Sully” Sullenberger, the famous US Airways hero pilot says of his profession. If you are in practice, I would suggest that you look for an alternative source of income to sustain you and your family in the coming years. Think more like a public school teacher…. do it because you love it, but do not expect it to be sufficient to sustain you financially.