"Are pediatricians and GIs generally open to NP/PAs handling the typical sick visits and other minor doctor appts? "

Two different issues. The GI docs are specialists, and wouldn't want to and shouldn't be handling day to day medical issues.

There's a huge shortage of primary care docs - Peds, internal medicine and FP, or more accurately a huge shortage of those sort of docs willing to take Medicaid patients, because they can't keep an office open with that patient population. Staffing a clinic with NP/PA providers MIGHT be able to stay afloat. Especially if they're affiliated with a system that can provide them with administrative back up/billing etc.

MM MD

"Unless the government is going to pay you, why are you obligated to do anything?"

Well, in my line of work, I'm compelled by statute to care for the patient irregardless of their ability to pay, if there is an emergent condition present. Until about 3 years ago, that meant about 35% of patients I saw paid me nothing. It's down to about 15% or so now.

Which I'm fine with. I make a more than adequate living either way. But yeah, if I want to keep my liscense/ability to practice, you're goddam right I have to take care of that patient.

"Why do doctors have a moral obligation to do their job without compensation?"

I took the Hippocratic oath. Among other things it states "I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirm."

I know it's old fashioned, but I took it seriously when I swore to it. Nothing has changed how I feel. Doesn't mean I don't like to get paid. But to me, it's part of the deal of being a doc, and the (mostly) good things that come with it.

MM MD

Your oath was to do no harm.

Your oath is old fashioned and only has been used against you.

You are a provider for an insurance company and an unpaid salesperson for a pharmacy company. You are not allowed to unionize. You have to certify every ten years. You have the DEA watching you. Medicare penalties (and ignorance doesn't matter) can be criminal.

You are also a documenter in an EMR system that was thrust upon you that you spend twice as long with as a patient. The CDC is telling you how many pain pills you can prescribe. Most of America sees doctors as the reason of the opioid epidemic. If doctors didn't prescribe pills, people wouldn't get it.

Your patients are angrier and more frustrated and you are one of the few people that they can vent that frustration. They still think you are rich. They don't want to pay for anything. You are required to do the prior-auth for them and are legally forbidden to charge for that. And you cannot even say anything bad about the insurance company. Because there is a non-disparagement clause. And 10% of your colleagues are sociopaths. And 100% of hospital administrators who view you as a cost center and irritant. Especially if you bed days per thousand are too high or your admissions are above the national average of 15.1%.

You have to stabilize an emergency. You don't have to treat anyone. You are a professional who provides services that should be compensated.

Who would ever choose primary care? The lowest $ per visit and most visits. 50 patients at $80 each vs. 20 at $200 each. If primary doctors were allowed to exploit the value of the patient like any other field, than primary would be gold. In healthcare, you go to jail for even taking $1 off a referral. That is why hospitals are buying primary practices. They can than control the entire playing field -- from specialist to surgeries to pharmacies to the hospital. Only way to contain costs.

Somebody woke up on the cynical side of the bed this morning.

This is incorrect, since the co-pay is the reason people buy supplemental coverage.

If you owned a restaurant and a man literally dying of starvation was begging for food, yes I hope you'd feel a moral obligation to feed him.

But more accurately:

If you were a salaried cook (doctor) making $350,000 at your restaurant (hospital) - one which is explicitly designed to feed (cure) those who are in a state of starvation (sickness / injury), mind you - yes, yes I'd hope you felt a moral obligation to feed the starving man with no money.

As it relates, what the f*** is wrong with you?

Someone link to Ron Paul at the primary debate a few years back essentially saying the uninsured should perish in the street while a frothy white crowd cheers. Gtd that Golfnutt is front and center.

This is like the 8th different random story renodoc has told in this thread over the past decade, and it's incredible that at no point has he even gotten closer to vaguely understanding the ACA. Like this story has, if anything, the least connection ever as it appears to be a story about how desperately people need health insurance?

The basic framework of the debate is too complicated for renodoc lol and the government gives this dude half a million dollars of taxpayer money a year for his "work".

I'll give you the other two, but you're gonna have to show your work on the accountant.

You could do a lot worse than the Hippocratic oath as a starting point to be an ethical physician. The fact that it is old fashioned doesn’t change that. If you want something newer the Geneva oath is more in fashion now, but it’s really about the same.

In terms of being a salesman for a pharm company, I’m pretty much isolated from that. I write for maybe 20 meds regularly, most of which are on the Walmart $4.00 list. More expensive ones (say antibiotics for inpatients) are dictated by the hospital drug committee – which AFAIK tries to balance efficacy and cost as best they can. I haven’t talked to a drug rep in 15 years.

In my practice the EMR is a mixed blessing but overall I’d rather have it than not. If anyone cares I can expound on the subject, but it’s pretty boring to be honest.

The opioid issue is a mess. When I was training, there was good reason to suspect that a fair number of patients were undertreated for pain. The pendulum swung WAY too far in the other direction, IMHO due to a couple of horse**** papers that were treated as gospel and the urgings of the pharm companies (may they rot in hell). There’s plenty of blame to go around. I’ve changed my prescribing habits quite a bit over the last 5 years in this area. I’m fine with the CDC giving guidelines, as I’m not equipped to sort thru the date and figure it out for myself. Just like I follow guidelines for the use of pressor agents in septic shock.

As far as old fashioned, I’m happy to be that way. I feel as a doc I have a duty to my patients and my community to do the best I can for them. I understand that others in my field may not. I’m only responsible for how I feel.

MM MD

You are paying more than $0 co-pay at the office with Medicare?

Tell me what office.

[QUOTE=DudeImBetter;50850715]

What about if 50 people were literally dying of starvation and begging for food. Moral obligation the same?

Then it is up to the person who is paying the salary to make the decision. If I am paying my lawyer $350,000 to work for me, I don't want him working on other cases. Even if it is a death penalty case and mine is a civil action.

They should not perish. The government should come up with some methodology to pay the healthcare cost of the services for people that cannot afford it.

Well, we are responsible for how we feel and act, but we are also part of something better always. You are part of the healthcare system.

You are one of the few that doesn't have to deal with pharma companies I guess. But it still doesn't make you immune. You are sending to colleagues who send it to pharma companies. The pharma companies take a huge chunk out of the healthcare system which could be going to you.

EMR has slowed you down. But there is something probably with consistency of notes --- yours and others. Don't you find it irritating though that you can't interact with other EMRs? Walled gardens. Also hundreds of papers on one encounter that are computer generated. Hard to decipher what even happened.

" You are sending to colleagues who send it to pharma companies. The pharma companies take a huge chunk out of the healthcare system which could be going to you.

EMR has slowed you down. But there is something probably with consistency of notes --- yours and others. Don't you find it irritating though that you can't interact with other EMRs? Walled gardens. Also hundreds of papers on one encounter that are computer generated. Hard to decipher what even happened. "

Probably not very helpful to use me as an example in terms of referral. I have VERY little latitude in who I refer patients out of the ED to. Shooting angles with the on call list is close to a termination offense in my group. I don't particularly need the money the pharma companies are "taking" from me - I'm more than fairly compensated. I'd rather that money stay in the pockets of the patients.

No question the failure of regulators to insist on EMR's being compatable is one of the biggest lost opportunities ever. Why this wasn't done is unclear to me, but it wasn't done with the agreement of docs - organized medicine repeatedly screamed about this. They weren't listened to.


MM MD

Thanks for the response. I thought GI was internist so replace that to make my question make more sense.

I notice the costs of these types of clinics has doubled in the past couple of years. Perhaps those paying cash are subsidizing the insured.

As for the rest, there may be some sense in this. Car insurance and warranties don't cover flat tires and dead batteries that are cheap to fix. It covers expensive situations. I've always thought health insurance should follow that model more. One would think that giving too much access to medical treatment that would otherwise be inexpensive if everybody that could afford to paid cash would cut unnecessary visits and leave the full coverage to Medicare and Medicaid. I suspect the lack of this type of coverage keeps some of the holdouts out of the market as rates soar.

I'm obviously not an expert though. I'm curious what studies and experts on the topic show.

You are smart. Why don't you think it was done? I am sure if you really think about it, on more of EPICal basis, you may start to recognize it

Why would a company that dominates the market want interoperability? Do you think Microsoft or Apple want interoperability?

Isn't amazing how little doctors were involve in anything they are the ones forced to use. And how little input they had into the design and use. And you are powerless to do anything about it.

You are also buying your drugs at the CVS. And CVS control the PBM (pharmacy benefits manager). You also buy toothpaste and beer while you are waiting.

http://www.forbes.com/sites/brucejap.../#53a8ce995aff

***Retail clinics may be creating new demand that adds to the rising cost of healthcare rather than reduces medical spending, according to a new analysis of the primary care option made popular by CVS Health CVS +0.03% and Walgreens.***

Who decides what is an unnecessary visit? In advance of them making an appointment at the "provider's" office? You truly only know AFTER they have come in it was an unnecessary visit.

Isn't amazing how little doctors were involve in anything they are the ones forced to use. And how little input they had into the design and use. And you are powerless to do anything about it.

This is certainly a failing of the medical profession. OTOH, since most doctors are seeing patients and running practices, it's not terribly surprising that the missed the chance to stop all that and change careers to become electronic medical record experts.

And yeah, we're pretty much at the mercy of CMS/medicare unless we're lucky enough to be in a practice area that doesn't need a hospital to function. Which most of us aren't.

MM MD

Who decides what is an unnecessary visit? In advance of them making an appointment at the "provider's" office? You truly only know AFTER they have come in it was an unnecessary visit.

A good number of states have "prudent layperson" statues that give some protection to patients vis-a-vis ER visits. I don't know (and I doubt) that those statues apply to this sort of provider, although they probably should.

MM MD

http://www.kevinmd.com/blog/2015/07/...ista-docs.html

Lawyers, accountants, and investment bankers are just as busy too, yet haven't given control up to administrators. And you know that these administrators have ZERO understanding of medicine. Or care. Yet they control every little thing you do. Your entire life. What happened to the once powerful American Medical Association?

You can't refuse at an ER, but you can certainly make them wait. For someone has an "emergency" headache, they can wait 6 hours. There is no "prudent" person that can deal with an impudent patient. All you can do is make the situation as unwelcoming as possible so they will not continually abuse the system.

Yes. Especially if you're making mid 6 figures, easily providing for yourself and your loved ones.

What's the reasoning to not feed people who'd die without food? Other than the principle of not being paid, what harm is being done to you here?

Like, until paying customers are themselves dying because there are waves of dying poor people who take their spot I'm not seeing ethical conflicts, and if that IS happening we've got an entirely different problem to solve.

Do all lawyer swear to a code that prevents them from not serving those in need simply because they can't afford services?

If so, then them the breaks.


We agree on something it seems.

As usual you provide no explanation at all to your "opinion"

I provide real world anecdotes and i live in a state that has a GOP governor that expanded medicaid.

This patient doesnt' have health insurance. Why not? Who should be responsible for his care? Me? Him? Some magical unicorn social worker who is supposed to hold his hand and walk him thru the process of signing up for his medicaid?

My brother was employed by our local hospital for two years doing exactly this.