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    It’s 4:57 p.m., and the Doctor is not picking up the phone

    It’s 4:57 p.m., and the Doctor is not picking up the phone

    That’s the format of a joke I often told about calling up state regulators when I was in private practice. They go off duty at 5 p.m., so the phone stops being answered at a few minutes before because a conversation started at 4:57 p.m. might go beyond 5 p.m., and they don’t get paid for that.

    It’s coming to a doctor near you because Obamacare regulations are pushing doctors to become employees rather than owners, as Scott Gottlieb writes in The Wall Street Journal, The Doctor Won’t See You Now. He’s Clocked Out:

    Big government likes big providers. That’s why ObamaCare is gradually making the local doctor-owned medical practice a relic. In the not too distant future, most physicians will be hourly wage earners, likely employed by a hospital chain….

    ObamaCare’s main vehicle for ending the autonomous, private delivery of medicine is the hospital-owned “accountable care organization.” The idea is to turn doctors into hospital employees and pay them flat rates that uncouple their income from how much care they deliver. (Ending the fee-for-service payment model is supposed to eliminate doctors’ financial incentives to perform extraneous procedures.)The Obama administration also imposes new costs on physicians who remain independent—for example, mandating that all medical offices install expensive information-technology systems.

    The result? It is estimated that by next year, about 50% of U.S. doctors will be working for a hospital or hospital-owned health system. A recent survey by the Medical Group Management Association shows a nearly 75% increase in the number of active doctors employed by hospitals or hospital systems since 2000, reflecting a trend that sharply accelerated around the time that ObamaCare was enacted. The biggest shifts are in specialties such as cardiology and oncology.

    Read the whole thing. It explains how this structure alters physician behaviors, and how the esoteric and complicated billing structure exacerbates the situation.

    I had dinner this weekend with a physician in private practice, who bemoaned the changes taking place and how much time he has to spend on “all that crap” other than practicing medicine. He doesn’t know how much longer he can take it, a feeling he says is common among his peers. They’re planning their exit strategies.


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    I’m fortunate to be one of those dinosaurs whose practice model still enables me to answer that phone 24/7. But the private, independent practice of medicine will continue to shrink as hospital survival incentives encourage bringing all physician practice under the hospital umbrella, into what they call ‘accountable care organizations’. Just saw an article this morning the nearly 50% of physicians are already employed directly or indirectly by hospital systems. The new paradigm will put physicians in several binds. One, the physician will be an expensive cost center. If the physician really puts the patient’s interests first, even more so. But the hospital depends on the physician (well, any licensed ‘provider’ they can get to do it) for referrals into the system to maximize gross revenue. So the long-traditional love-hate relationship between hospitals and physicians will continue, only now the hospital will control the money – unless the physician ‘behaves’, he/she will be out of a job. The tension between financially independent entities worked to the benefit of patients, but it will ‘my way or the highway’ from now on. What was once a proud profession (deservedly so) is rapidly become a trade. Don’t get me wrong, trades are good for many things, but those of us educated to utilize our assessment skills and individualized independent judgment in the service of our patients don’t fit well into the trade paradigm. In the new order, the customers will be ‘diabetes’, ‘hypertension’, ‘coronary disease’, ‘lung cancer’, etc., rather than unique human beings.

    My primary care physician sees me the day that I call, if it is before 3:00. After 3:00, I am seen the next morning. I can understand that. What baffles me is that Medicare pays him about 25% of what he submits and what he submits seems very reasonable.
    My concern is for my children and grandchildren. They will suffer under the boot of ObamaCare.
    The “elites” [democrats and wealthy republicans] will have all of the healthcare that they need and want.

    Mister Natural | March 28, 2013 at 10:57 am

    Here’s what’s coming gang

    Man dies after doc takes lunch during kidney op
    Published: 6 Sep 12 11:44 CET | Print version

    A 72-year-old man having a tumour removed from his kidney died after the chief anesthetist and nurse took a lunch break in the middle of the surgery.
    The incident, which took place at the Lidköping hospital, has prompted stinging criticism from Sweden’s National Board of Health and Welfare (Socialstyrelsen).

    The 72-year-old went under anesthetic at 10.45am on the day of the operation, which took place in January 2011.

    At noon sharp, the head anesthetist left the operating room to go for lunch. Fifteen minutes later, the head nurse anesthetist also left the patient and went for lunch.

    No other anesthetist was called in to take over responsibility for the doctor who was on his lunch break.

    And while another nurse was brought in to cover for the nurse anesthetist, the nurse who arrived came from the orthopedic ward and wasn’t familiar with the respirator to which the 72-year-old was attached.

    Suddenly, the patient started hemorrhaging and his blood pressure started to drop, sparking a “chaotic” situation.

    As the patient’s condition became critical shortly before 1pm, the substitute nurse tried desperately to reach the lunching anesthetist, but to no avail.

    When the doctor and the primary nurse anesthetist returned to the operating room, they discovered that the patient’s respirator had been turned off, leaving him without oxygen for approximately eight minutes.

    Despite immediately starting resuscitation efforts, doctors were unable to revive the man, who had suffered irreparable brain damage and died several weeks later.

    The man’s daughter subsequently reported the incident to the health board, which on Tuesday issued a harsh critique of the hospital’s procedures.

    “The operational planning, which allowed for the responsible doctor and nurse to take lunch breaks at the same time without any other doctor taking responsibility for the patient, entails taking an unacceptable risk,” the agency wrote in its findings.

    The agency also found fault with the fact that the doctor wasn’t reachable by phone, as well as with the decision to hand responsibility for a high-risk patient with a single nurse who lacked sufficient knowledge of the equipment in use during the operation.

    “The National Board of Health and Welfare finds, however, that the operation’s lack of organization as well as the chaotic situation which occurred was the underlying causes behind the misjudgments and insufficient care,” the agency wrote.

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