A “small community doctor” still needs to get paid, and even if they’re generous with their billable hours, the other parts of the medical system (specialists, medication, etc.) will still be charging at the usual insurance-inflated costs, which is often beyond the reach of a small isolated rural community with a constrained community.
Another Canadian chiming in. I used to go to a neighborhood clinic, and in a non-ER emergency (urgent but I don’t think I need a hospital) event, I’d see whoever was on shift. But I did have a regular doctor there, who knew me and my history, for close to twenty years. During the pandemic I didn’t see her in person very much, but whenever I needed a prescription renewed, she’d call me and we’d talk about what was up and how I was doing. I was pretty happy with the situation.
On one of those prescription calls a couple of years ago, she said that the block on which the clinic sat was being expropriated by the province for the construction of a new subway line (long boring Toronto story), and the owners of the building had decided not to move it. So she found herself a position at a youth clinic, and sadly, as I’m an old fart, I no longer had a family doctor.
What this meant was that I had to start looking for a new clinic, all of which seem to be either a) hole-in-the-wall offices in random neighborhoods, of b) assembly line franchises, all of which had basically an interview process to get on board. I asked the Facebook hive mind, and put in applications at a few places. I eventually met with my new doctor over Zoom, and really it was my choice to go with her after our talk, which was fine, and I don’t know how much the remaining COVID restrictions (they’d mostly wound down here by then) affected that process, but it did feel like I was being interviewed as well.
I’m mostly happy with where I wound up: my new doc is very good, and sympathetic, and knows her stuff. She doesn’t work weekends, though, so any time I need to get something checked out I have to take a triple-long lunch break from work and trek halfway across downtown to the clinic. And presciption renewals are no longer free unless they’re a part of said visit; if she just does it over the phone I get a bill for it, not covered by the province. And when I book online for an appointment, I pretty much have to limit my reasons to one, maybe two if they’re minor, becuase I’m going to see her for maybe ten minutes at most, one of fifty people she’ll see that day (the clinic does have the flow down to a science, I’ll say).
No idea how older folks who can’t navigate the interwebs as well as I do manage to get a new doctor nowadays. My octagenarian parents have a family physician they don’t like very much but they don’t have much in the way of options, and don’t have the wherewithall to actively seek a new one. I have no idea if my doc is happy with the situation, but I don’t see why she wouldn’t be, working a few days a week in a clean, factory-like clinic, but I know the patient connection has definitely suffered as this stuff becomes more online and streamlined.
I’m not at all sanguine about the likely impact of The Biggest Corporations and Institutional Investors finally unable to resist the clarion call of the ~18% of GDP that health care represents:
Not that medicine isn’t a business, and hasn’t been a business all along, but the more nameless, faceless entities, corporate raiders, and arbitrage types we get at the helm, the more the spreadsheet will crowd out the humanity.
Provider friends have talked for years about increased pressure on diagnoses and coding, and greater pressure on productivity (more patients → shorter appointment times, coupled with greater average acuity = no bueno).
Nobody’s winning right now.
I’m a bit pessimistic about the overall direction, the likely impact of further consolidation, and the steadily increasing effect that the bean counters will have on quality of care and satisfaction among those delivering it.
[Husband of FNP at a family medicine residency program]
Hijack hidden at request of poster
I know this is FQ, but we’re already getting pretty far afield, so I think I’ll comment once on the where the future of health care is heading, in light of @DavidNRockies’s article, and the repeated anecdotes by all.
The analogy I’m thinking is early Boeing Aviation as opposed to the current Boeing iteration.
Early Boeing was largely run by engineers, or at least those that grew up through the company with an emphasis on competing through the quality of the product (huge generalizations, I know, and that leaves out military procurement, and everything else).
Which was apparently profitable, but not profitable enough. Kind of like what we’re seeing in the medical field, and especially for family medicine.
In the modern Boeing era, we saw an emphasis on profitability above all, and every decreasing control of the actual product between outsourcing and third party work on the assembly. And fewer and fewer checks on said quality of work and training.
Result? Huge profits! Aaaaaand now multiple plane-based disasters.
For this thread - it sure looks like the industry will follow the same path. Small, independent contractors: individual family practices, small partnerships and the like being absorbed into ever-bigger conglomerates, and profit motives allowing for ever increasing sloppiness in the final product until an unavoidable number of people end up in poor health or dead.
Last I’m saying on that, as I think it’s as far as we can go while staying true to the OP. Someone may want to spin off a new thread though!
Such subsidies along with many, many other enticements (including student loan forgiveness) have been offered for decades, but have largely failed to change the picture of gradual decline as regards primary care in underserved areas.
This review about Current Programs and Incentives to Overcome Rural Physician Shortages in the United States: A Narrative Review addresses a lot of things that have been tried, notes a lot of the common pitfalls, and offers more ideas too.
It couldn’t possibly be that they are end users who have their own ideas about how they should be able to interact with software, and what they need that software to do, and perhaps are tired of their working lives being constrained by gatekeepers who keep telling them that what they want can’t be done?
I only ask because I have had that experience, in a different field, as an end user. Over time it turned out that it could be done, but it was a lot of work.
What we docs want is an EMR that works for us and the patient, not one where we have to work for the EMR (by doing all sorts of work-arounds and back-flips to do normal charting tasks). I had great expectations of how our EMR would solve so many of our record-keeping issues and streamline and improve patient care once it was implemented. It only made those issues worse. I’ve heard this complaint from many of my friends and colleagues over a wide range of EMR systems.
I always respected our IT folks; my daily functioning depended on them. And I knew they didn’t design the system or make the rules, so I didn’t vent at them. In fact, we generally complained about the horrors of the system together.
BTW, management was always telling us that we physicians shouldn’t be doing tasks that others were able to do, we should stick to doing tasks that only licensed physicians can do; hence increasing income. However, management also refused us the use of scribes to help document in the EMR, educators to do patient teaching, clerical help to arrange for organizing documentation, etc. etc. I even spent time stuffing envelopes with my notes to my patients with results because there was no one else to assign such duties to.
Not sure aout the USA, but the experience in Canada is that doctors, like many educated college graduates, spent a lot of their time in big cities and actually prefer that life to a more backwoods rural environment. Canadian small towns have been having serious problems attracting doctors for decades, and I vaguely recall similar complaints in the news from American small towns. Sometimes the town is lucky and finds a docotr who prefers the rural life or the great outdoors. Canadian schools also make an effort to recruit students from remote areas.
Usually the problem is the other way around - one doctor in a small town leaves or retires, leaving the other(s) so overworked (and constantly on call) that they give up too.
I’m not sure why clinics aren’t the norm. This seems to be the typical setup for dentists - most around here seem to be in bvery organized coopertive clinics or partnerships, several dentists sharing a facility and receptions, assitants, office staff etc. Big business is not (yet?) involved.
Huh. My dentist is a one-woman shop. Well, she has a receptionist and a couple of assistants, but she’s the only dentist. My husband’s dentist is, too.
As a retired hospital pharmacist, we had a 1.0 FTE informaticist, and a few other people who knew how. What you describe - adapting the software to the user - was exactly their jobs.
My dentist’s office is a husband and wife, with of course hygienists, assistants, and a receptionist. They’re much more likely than physicians to be able to be independent practitioners, and some of them are even insurance-free practices (i.e. cash only). If you have dental insurance, you can pay and then file on your own for reimbursement; many psychologists and other independent practitioners are also following this model.
Mine does take insurance, but they do offer a significant cash discount. “Cash” includes checks or credit cards; in other words, paid at time of service.
“cash” also means they didn’t have to deal with all the red tape of the insurance company.
It’s been a while since I had dental insurance but my memory of it is that it is mostly worthless. Maybe pays for checkups twice a year or something. I don’t remember anything about dental insurance that was good. It never seemed to cover the big bill items (which seemed most things dental).
I wonder if there might have been some sort of event in the past, oh let’s say, 4 years and 1 month or so that would have motivated a lot of older doctors to retire.
That’s my explanation as to why my PCP has changed three times in the past four years when before that I had the same one for 7 years straight.
That’s because the greedheads shaped the whole thing.
It’s not insurance. You’re not paying somebody a bit extra to average risk over a pool. They pay the routine, affordable, predictable part, and leave the patient on the hook for the unusual large unexpected expense. In fact, many of the participants in this system have quietly started referring to it as a “plan”. It’s the opposite of insurance.
I think the same thing has been happening to prescriptions. It had more to do with a middleman working over both the provider and the consumer parts of the system, to insert themselves into a system they’re not actually helping, and get some of the income stream for no productivity. I think private employer plans even started kicking money back to the employers whom they had to convince, to the point where somebody realized the employer doesn’t actually need to pump much money into the system, and then other third parties started offering what appeared to be free insurance plans, like “GoodRX”. When I realized that my own employer’s prescription plan was causing the co-pay to be higher than the price people without any insurance were paying, and they were also doing things like limiting you to 30 days of meds (which gets your foot traffic back into the brick-and-mortar store three times as often), it occurred to me that our “insurance” had negative value to the patient and that the “insurance” company was treating employee time as if it were free. Employees are running down to the store and wandering around there killing time by buying crap while waiting for the scrip to be filled, and they’re doing it during business hours because that’s when the pharmacy department is open. I started chasing after the decision makers in our company, who were acting as though there were kickbacks or something, and got encouragement from the owners of the company but pushback from the functionaries.
Just seems like so much else in the US – it’s all moneymaking schemes.
Are you in a rural area? Some states have a program where they grant a full ride to medical school if you agree to practice in a rural area for a certain number of years. This would imply a higher churn rate for familly practies in rural areas.
My husband is a physician, and this is pretty much his exact rant. He is So OVER being told how to manage his patients, how long he can spend with them, and getting hauled over the coals when he makes someone angry by pointing out that he cannot help them feel better if they don’t at least try to follow his directions.
He loves medicine, he just is so incredibly frustrated by the intrusions of admin and insurance into his job.
It’s mostly worthless because it pays so little that it’s hard to find a dentist who accepts it. Mine actually did cover big items like braces and bridges and dentures, etc but when I first looked for a dentist who accepted it, I ran into a lot of “not accepting new patients” or a six month wait for an appointment. But at least the non-participating dentists were OK with filling out forms and sending them to the insurance company so I can get partial reimbursement after I have paid in full - I’m not sure if doctors do that any more.
The last time I had dental insurance was in the late 80s when I was living in Philadelphia. Everything in Philadelphia, IME, had a scam involved.
I went to a dentist for some routine stuff. He sat down after and told me my insurance would only cover part of what I owed, but don’t worry, he had my back.
He wrote it up as though I had a complicated root canal performed. My insurance covered most of that, and he wrote off the bit that wasn’t covered. He was such a smooth talker. Never went back to him.
Dental insurance (or dental benefit) seems to work much better in Canada - but perhaps that’s because they don’t have the example of medical insuance to mimic. Plus, since health care is covered, the only significant incentive health benefits that good employers can offer are dental, prescription, and eyecare. (Mine also offers coverage to a limit of $500 for massage therapy, physio, chiropractic, etc.)
I’ve been lucky that my dental covers 100% for routine, 80% of fillings and crowns, and 50% or orthodontics - which I understand is typical. (I ran into a retired employee that told me of her travails with the insurance company. They don’t cover dental implants, but after an bit of argument, she made them pay for the crowns on her implants because she specifically had that part billed separately).
Prescriptions are almost completely covered; but then, because the provincial health authorities are the largest customers, they ensure that drug prices are kept down. I attended a presentation by the company benefits team once, and they mentioned the process for prescriptions - the first time a prescription is written, it must be for 30 days. This was because humans have varied reactions to drugs, many physicians practice medicine along the lines of “try this and see if it works”. New prescriptions are often changed shortly after they are first tried, no point in wasting months of drugs. Once the first month is done and it appears this will be a continuing treatment, they wanted prescriptions to be 90 days at a time, so that they paid only one dispensing fee every 3 months.
Most major benefits companies work off the approved fee schedules (drugs and dental) so a person is on the hook for excess fees. As a result, almost every dentist and pharmacy charges the fee schedule, and most will do the insurance submission directly (online). The only time I ran across a pharmacy that charged a higher dispensing fee, it was across the street from a major hospital and had what might be described as an almost captive audience, people who came in unaware of the hike; since they were used to paying (typically) 20% anyway, they could be hit with a few extra dollars and not notice. I just noticed because between my benefit and my wife’s I pay zero. Even a $3.00 extra cost evokes the question “Why?” (Note my wife’s insurance will pay the 20% not covered by mine, but only up to the fee schedule amount)