In many, many of my previous posts, I’ve complained about the bigotry against and ignorance of family medicine by the rest of the medical establishment and the greater society. Today I will challenge my family physician colleagues to do more.
A recent survey by the AAFP found that fewer than 20% of AAFP members have hospital privileges and fewer than 42% provide office-based procedures. These numbers are pitiful.
First the hospital privileges: I understand the economic realities facing many family physicians whose offices are not near a hospital. When I ask them about seeing their hospitalized patients, they say by the time they drive 30 minutes through traffic each way, they could have seen 4 patients in the office. Allowable hospital professional fees don’t nearly match this revenue. That reality and other anti-family physician funding policies by CMS and the private insurance companies mean some family physicians lose money to see their hospitalized patients. Shared call and hospital coverage groups can lessen this burden.
But for a field that claims that continuity and long-term patient relationships are such a foundational trait of our profession, to not see our sickest patients is nearly inexcusable. Basically, these family physicians are telling their patients when they are the sickest, the most vulnerable, and the most scared, “Hope everything goes well for you in the hospital. I’ll see you later if you make it out alive.”
For the procedures, this is much more in the control of family physicians. Most patients don’t want to bounce from clinic to clinic to have different procedures performed. Family physicians generally believe the common office-based procedures are paid fairly by CMS and the insurance companies. I’m not sure why this FM procedure percentage is so low. Weak residencies that train young family physicians to be helpless combined with practice environments that discourage procedures are some of the explanations. This problem is generally easier to fix than the hospital problem. A lot of family physicians simply need to grow a spine and expand their personal basket of services.
In a few weeks I will take my turn covering the hospital for my group. It’s a wonderful diversion from day-to-day clinic life. It’s fun to teach residents how a family medicine philosophy works well in the hospital, not just the clinic. And I even get to do a few extra procedures. It’ll be fun. I wish more family physicians shared this joy.
Actually, fewer and fewer sub-specialists do any in-office procedures any longer: they’re done in out-patient surgery centers, GI centers, skin centers,etc. The center collects a hefty facility fee and the doctor has almost no overhead.
Unless you’re part of a huge group that has the clout to extort facility fees and jacked-up payments, procedures can be money losers.
I sympathize with your point of view, but we have to acknowledge that family physicians are fighting for their professional lives. Finances are the overwhelming factor in practice management decisions.
That our professional society still refuses to address this in a realistic manner is a disgrace.
Maybe it’s the training programs that have to do with how family medicine docs think, I don’t know how other family medicine programs operate. What I do know is what Dr Young has expressed many times as his educator’s perspective on what family docs can and should do. It’s terribly apparent to me that a wealth of talent and capabilities are being wasted and supplanted by a lot of high(er) cost care that does nothing more but deliver a much larger bill. That’s a waste of talent and money and it is costing us dearly. I know when I went to my new family medicine physician, and asked him to take a look at a growth on my neck, he wasted no time in expressing his suspicions about it. BUT, instead of shipping me right out to a dermatologist, he told me that he would do the punch biopsy in his office because it makes no sense to run up larger expenses than necessary. When the result came back positive, he took the time to explain to me that the skin cancer was deeper than he could go after, so his office located a Mohs surgeon for me and made the referral – promptly.
But when I read a comment such as the one above, i.e., where the surgery centers collect a hefty fee, it bewilders me that these layers of cost and additional pieces of the “pie” are stacked up to make care that much more costly. We’re missing the message here – that family medicine docs should just be able to spend the time doing the many things they can and should do, instead of functioning just as referral services. We should recognize the many things they can do in their offices and simply pay them correctly for the time they spend doing what we all know will be much more cost-effective care delivered as capably as anywhere else. Note that I didn’t say pay them more for any particular item, but simply pay family docs fairly for the time they should be able to take to be comprehensive care deliverers.
As far as hospital care, all I can say is that if I were in the hospital, the one face I would want to see there in the forest of strangers is my family doctor. It lends a steadying, reassuring presence that I think is psychologically important. I know it’s more difficult to tear away from the office, and Dr Welby was a nice television character. But again, if the quality and continuity of care lends a psychological benefit in the value proposition for patients who are seriously ill, than I think it’s well worth considering – somehow – to extend the presence of the family physician into the hospital room. Being seriously ill or injured and hospitalized is not easy, and the steadying presence of the physician who knows us best can, I think, be translated into a wise and cost-effective factor in the care process.
You seem to be a bit heavy on FP’s here. The financial stresses are heavy. I would have to round at 4 different hospitals in my community to keep hospital privileges–not worth it. I do skin procedures in my office, helped by the fact that I do 80% Medicare, but it sure wouldn’t pay to resume colposcopies in that age group, or OB.
You mention hospital rounding for your group. I imagine your office is near the hospital. I also imagine that means you’re at the hospital all day, every day, that week. Most FP’s don’t have that luxury–they round daily and still have to work at the office.
You describe the frustrations well regarding the pressure FP’s face, but I think you are placing the blame more on FP’s than they deserve.
Dr. Sautter,
Your descriptions of some of the practical barriers working against family physicians caring for their patients in all settings are very appropriate. I just ask that you dream bigger.
What if Medicare paid the personal physician to take time to visit his patient, even if he doesn’t write a note? I’ve heard many family physicians who make these social calls talk about how much they help the care process, from working to arrange care after discharge to simply explaining what’s going on better than the ologists.
We’re not paid for the comprehensive work we do in the outpatient setting, but neither are we or anyone else paid for the same basket of services in a hospital. It’s the same fundamental problem with the CMS E/M rules — they were written by ologists for ologists.
All I ask is that you not lose sight of the ideal, and keep up the good fight.
Richard
No, I’m not losing sight of the ideal, but it is more into the distance than ever before.
Your thought about the FP rounding on his/her patient: That wouldn’t help me because, remember, there are 4 different hospitals for me to round at. That could only happen in an ACO model, where I would only have to have 600-800 patients on my panel rather than 1600 (at least, that’s what I am told–whether I believe it is another story). I personally believe that much of this problem comes from the patient not having more personal (or should I say financial) stake in the system. Pay the FP a $30 co-pay to remove that skin cancer or the derm $50 to do the same. At that cost, hire the expert. Maybe if the specialist co-pay was $150, it would be a different story.
The FP/primary care numbers are too small to carry much weight anymore. It will need to come from Washington, I’m afraid, and probably will take heavy Presidential initiative to support primary care as it should be supported and promoted. Know any family docs up to running for President?
Great blog, but I think you missed the mark here.
Your post comes across as another version of “family docs need to do more work that they won’t get paid for because they’re good guys/gals and it’s the right thing to do.”
We’ve been hearing that for 20 years, and that attitude has destroyed our specialty.
Dream bigger? How about a professional society that represents the interests of its membership!
Dreaming bigger includes dreaming that a membership will insist that its leadership pick the right fights. In our control now — provide procedural services that do pay fairly well to keep your patients from having to wander from facility to facility to have basic procedures provided. Out of our control now — the existing payment system that forces us to give away our work.
Yes, I am one of the family doctors who no longer goes to the hospital. There are many reasons for this but one of them is my on call group stopped going to the hospital and I tried for four years to stick it out but finally am no longer able to do
And guess what almost all of my patients who did get admitted I did not admit, my on call doctors did so my patients were still pissed off because I was never there to admit them.
And last but not least is do you really want to be admitted by a doctor (me) who only admits one or two patients a month. I want a doctor who admits 20-30 people
I want a doctor who sees at least 10 pneumonias a month or mor a doctor who sees 20-30 heart attacks or heart failure.
I am SO glad that I have great doctors to help me take care of my patients in the hospital because my goal is to ke them out!!
I want a competent confident family physician making excellent judgment calls about the complexities of my care in a hospital just like he or she does in the office. I want a payment system that encourages family physicians who know me well to care for me in whatever facility I’m at.