Health care mandate in the United States

At a health care town hall last year, our representative said that US citizens have not given Congress a mandate for health care.

I raised my hand. “I beg to differ. The mandate is already law. The law says that no person in the US can be refused care at any emergency room. We have the mandate. Unfortunately the emergency room is the most expensive and cruel and last minute care that we could possibly choose.”

Expensive: any ER visit costs more than a whole day of visits to my rural family medicine clinic.

Last minute: the emergency room doesn’t do chronic care. Their purpose is to 1. try to stop someone from dying and 2. decide if the person should be hospitalized or should follow up in clinic. They do not do prenatal care, treat high blood pressure, treat diabetes, depression, high cholesterol, alcoholism. They do not do chronic care and aren’t meant to.

Cruel: you can go to the emergency room to try to keep from dying. Say you go coughing blood. They find a lung cancer. Now, you have a choice: be treated and maybe you will survive or maybe you will die anyhow and your house will be sold to pay for the medical care. Do you choose to go home instead and die so that your family inherits the house?

The United States spends twice as much per person as the next most expensive health care system in the world and they have universal health care and we don’t. We care more for corporate profit then US citizens and visitors health. I cringe when the discussion is about health INSURANCE not health CARE.

I am a physician but I also own my own business. As a small business owner, I think that I will soon have to close. Why? I am in my 50s with a daughter. I think that within two years my HEALTH INSURANCE will cost more than I pay myself. And I will close the clinic.

We need health CARE not health INSURANCE. The Obamacare law said that health insurance companies can ONLY keep 20 cents of every health care dollar they collect, down from 22.5 cents. They have to spend 80 cents on health care. For medicare the overhead is 2-3 cents per dollar.

Medicare for all, single payer. Put 97 cents of every health care dollar to health care instead of only 80 cents. Or shall we continue down the road to small business and local government collapse and citizen health collapse?

Congress, you can’t wheel and deal your way out of this one. We want health care for our dollar not insurance.

For the Daily Prompt: wheel.

bye bye doctors

stop this healthcare bill… until there is transparency… or this will get worse.

 

I am grieving, watching doctors leave.

I have been in my rural county, 27,000 people, for 17 years.

Doctors are leaving. Wake up, United States.

The trend when I got here was that we had 14 primary care doctors and 5 midlevels. For years, we lost one primary care doctor a year. I would grieve and it would mean more work, every year. We would get a new doctor, but often there would be a gap… I made up a game to help cope with grieving. I call it “Local Doctor Survivor”. I would bet on the next doctor to leave and also on their trajectory. One of three: nice doctor, angry doctor, doctor labeled nuts. Burn out.

But…in 2015 it jumped. Suddenly we had 3 primary care doctors and two midlevels leave. Uh-uh. One was a husband and wife, doctor and nurse practitioner. One switched to being a hospitalist. Another left. And another midlevel. By then, we still had 14 primary care doctors, but the number of midlevels, nurse practitioners and physicians assistants had risen to 12. Ok, 12 plus 14 is 26. One fifth left. That is a bad trend.

In 2016 another physicians assistant retired. One of the best. I stopped counting who was leaving. Until another doctor announced they were leaving in February 2017. One of the best. That doctor said that a 20 minute visit generates 1 hour of paperwork. If one works “full time” the quota of patients is 18 per day, 72 in the four day week, and that is 32 hours four days a week of 20 minute visits. Generating 72 additional hours paperwork. That is 104 hours a week. Unsustainable.

The 2016 salary information is out for primary care. The “median” family practice physician in the US makes $168,000. Ok. But every doctor given as an example works 60-70 hours a week. Maybe that salary is not as good as you think. Because they are quitting.

Our neurologist retired, in about 2010. I was bummed. The county north of us has 75,000 people. They had two neurologists. Both left in the last two years. The county south of us has 350,000 people. They had five neurologists. Two have left, including my current favorite. For the first time in 17 years I have a neurology referral refused: and not one, but two. Send them to the big city, says one. The other just says no.

I call ENT and he bemoans that now they are down to three in the county. Another left. Three there, one on the county north of me, great, we have 4 for 450,000 people.

I get a letter from one of the two neurosurgeons in Seattle that I like best. In 2016. He is leaving to go do medical administration in another country.

Our three counties are down three dermatologists. One sent a letter. “I am quitting on October 1, 2016, unless ICD-10 is cancelled.” ICD-10 is the new manual of diagnostic codes. It was not cancelled so that dermatologist quit. We have to code every diagnosis. ICD-9 had 14,000 codes. ICD-10 has 48,000. I am memorizing the new ones. I10 is hypertension. E11.65 is type II diabetes in poor control. I used to be able to write a prescription for diabetic supplies, lancets and glucose strips. Now I have to include the ICD-10 code on the prescription and often the pharmacy cites medicare and demands that I fax proof that I have seen the patient and that the patient does indeed need the prescription. I frankly have better use for my brain than memorizing the ICD-10 codes, but whatever.

Another clinic closed in the county north of us and our county. Then the main clinic closed in the county south of us. Within two weeks. 3500 patients needing primary care providers and refills and we can’t get old records because the rumor mill says it was a “hostile takeover”. That is, the person who owned the clinics quit paying the bills, so the electronic medical company won’t release the records. Great.

I have been absorbing about one new patient per day worked since March, but I am getting tired and will have to back off.

Meanwhile, our county hospital has been hiring specialists. Gynecology, new orthopedists, dermatology. Great, right? But currently most specialists won’t take a new patient without the patient having a primary care doctor. Why? Well, one of the new trends is that the specialist says the patient needs something but that I should order it. Yep. Had one of those yesterday. The specialist says I should order it. It’s a veteran. So I get to fill out the VA authorization paperwork with the ICD-10 codes and the CPT code for the study, fax that to the VA, call the patient and remind him to call triwest, because if the patient doesn’t call then triwest throws the authorization paperwork out. And the specialist makes more than 5 times the amount I do. Maybe I should retrain. I am a specialist: family practice, three year residency, board certified, board eligible. But….. I have little value in the United States.

We are seeing Veterans in spite of the extra paperwork. Triwest is sending us 5 from Whidby Island. They have to take a ferry to see me. Because no one on Whidby is taking veterans. My receptionist complains to triwest about all the doctors leaving the Olympic Peninsula.

“No,” says the triwest person. “Not just the Olympic Peninsula. The whole west coast of the US.”

 

http://www.aafp.org/news/government-medicine/20170620senatespeakout.html

The pending healthcare bill

I’ve just seen an article from the American Academy of Family Physicians that more and more solo and small practices are closing.

Call your Congressperson, because the thing that is most likely to close my small clinic and clinics near you is the latest healthcare bill passing.

That is, to be even more specific, the thing that will most likely close MY one doctor clinic is THAT I WON’T BE ABLE TO AFFORD HEALTH INSURANCE.

Really? Oh, yes.

I was sick for ten months, June of 2014 until April of 2015. I managed to hire a physician’s assistant by November of 2014 and I returned to work April of 2015. I was only allowed to work half time initially, for a year. Actually, quarter time. Because the latest article on primary care has average salaries. What interests me is that every doctor they interviewed who is earning the “average” is working 60-70 hours a week.

So when I returned to work I was allowed to work half days. That is, four hours a day. So, 20 hours a week. One third to one quarter time.

Also I was paying for my own insurance and I had a $5000.00 deductible. Which I had to pay in both 2014 and 2015. I also had to spend retirement money and savings to keep the clinic open. Negative earnings and using up savings in 2014 and 2015. I worked 20 hours a week for a year. And guess what? My income for 2015 qualified me for Obamacare in 2016.

No deductible. By April of 2016 I am released to “full time”. But I have learned my lesson. My sister died in 2012 and my father in 2013 and these deaths were the trigger for me getting sick. I can’t retire yet. I have burned through savings for three years. I choose to work 40 hours a week.

This means that I stop seeing patients by 2:00 pm. I still do an eight hour day because there is at least three hours of phone calls, insurance prior authorizations, lab results, x-ray results, specialist letters — like yesterday. The specialist says the patient should have an MRI. But the patient is a veteran. So the specialist says I should order it. That means filling out the paperwork for the VA authorization, mailing the order to the patient, calling the patient to remind them that triwest will throw my order away unless the patient calls to get the test authorized. Yep. And the specialist gets paid 3-4 times what I make. How nice.

I also choose longer visits. The local hospital kicked me out of their clinics because I protested about a daily patient quota. I was not diplomatic. And I don’t care, because two years later they decided I was right and lowered it. And I like my private clinic better.

BUT if Congress passes this healthcare bill and I return to over $1000.00 per month health insurance for me and a 19 year old daughter, and with a $5000.00 deductible…. I don’t know. I think I will run a Go Fund Me and ask President Trump and my Congresspeople to donate to pay my health insurance and keep me open.

And by the way: I think Congress should have the same health care as their constituents. Give the ones over 65 medicare and the ones under 65 medicaid. Let them experience what older Americans and disabled and poor experience. And don’t let them bypass it with cash, either.

Call Congress. Stop the bill. Thank you.

 

I am a board certified board eligible family doctor for over 30 years, who has chosen to do rural medicine the entire time. I am small and ordinary…. like this song sparrow.

For the Daily Prompt: meddle.