What’s a Physician to do?

by Tejas Desai, MD
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Nephrologists across the land are feeling the financial pinch. You’ve heard or read about physicians who refuse to see established patients because they aren’t reimbursed enough. What happened to their sense of altruism? Where is their obligation towards their patient? Don’t be surprised, but the obligation is still present and the altruism hasn’t disappeared – both have been usurped by the increasing financial obligations that Nephrologists have. Costs such as electricity and gas, telephone, paper, and rising mortgage interest rates all affect how we conduct our businesses. It is a common myth that physicians are protected from these expenses; they aren’t. In most states, physicians have to pay the same amount for these business-related expenses as everyone else. To help curtail the burden, the capitalist in us would simply ask management and/or our clients for more money. Raise the rates of services or goods or charge more for less and recuperate the money that you need. In many professions this technique is commonplace and expected, but not in medicine. Physicians can’t raise their rates for an office visit or consultation because they don’t control those rates. The government and insurance companies tell physicians which services can and cannot be charged, and how much each service is worth. Physicians can’t offer less service for more money because the altruistic physician believes all patients (regardless of race, class, etc.) should receive the same quality of care. What’s the physician to do?

1. Unionize and collectively bargain. This negotiating tool is commonly seen in the world of sports. From the multi-million dollar athlete to the meager-earning rookie, a union of like-minded laborers pool their #1 resource together, themselves, to bargain wages, playing conditions, and contracts with the owners. Something similar could be done in medicine, with a large number of physicians negotiating reimbursement from insurance companies. Why accept $20.00 for a primary care visit when as a group, you could negotiate $30.00 per visit? Because first, physicians across specialties and states would have to unionize together. Thus far, such a national or regional union of physicians does not exist. Perhaps it is the stigma of being associated with a union – historically unions were created by “blue” collar workers and physicians have considered themselves “white” collar for decades – or the inability to reach consensus on the value of the services that we provide, Or perhaps it simply takes too much time to organize and legitimize a physician-union when so many physicians are already overworked and under-rested.

2. Unionize and strike. See #1 above. If unionization amongst physicians is difficult, physicians-on-strike would be highly unlikely. Striking physicians would have to, at some level, abandon the Hippocratic Oath and ignore ill patients who need their help. Since closing access to health care for personal benefit goes against their altruistic nature, physicians-on-strike may be more of a dream than anything else.

3. Demand, upfront, that patients pay more for the services rendered. Sounds like a good idea. Inform all patients of the total price of each service before you deliver those services, and provide it/them only if the patient agrees to your price. The problem with that option is that the financial relationship that underlies the physician-patient interaction is between the physician and the insurance company, not the patient. No matter what the price to which the patient agrees, the contract is between the doctor and the insurance company and those contracts are usually difficult if not impossible to negotiate.

4. Refuse to see patients that have insurance. Commonly known as concierge medicine, the physician decides to revert back to the “fee-for-service” model. Here, the physician and patient enter into a mutually agreeable financial relationship related to the costs, type, extent, quality, and expectations of medical care. No middle man/company is needed. An increasing number of physicians are opting for such a model, but many Nephrologists cannot. Dialysis is a Medicare entitlement; thus patients will, at some point, be covered by a health insurance plan. Once that happens, the financial relationship is no longer with the patient (see #3) and any previous contract with the patient would be null and void.

5. Refuse to perform or render services that reimburse poorly. Perhaps feasible in certain surgical specialties, this approach would fall apart in the world of primary care. Which services would be underperformed? The annual physical exam? Completion of work- or school-related health forms? Checkups for allergies and headaches? Many of these encounters form the bulk of what primary care physicians see. Although they may pay little, the sheer number of such encounters would make it fiscally irresponsible to curtail those services.

6. Move to another country and set up shop there. Possible, but not practical. Physicians, like other individuals, are not overly inclined to uproot their families and start life in an entirely new country and culture. Thankfully the US Medical Doctor degree is recognized worldwide, making it somewhat easier to make the international transition. However, this option seems to be an unlikely scenario in the near future.

7. Work for free. This way, a physician can provide the highest quality care possible without any concern for billing, coding, and confusing paperwork. Besides, physicians wouldn’t be able to complete those tasks anyway without money to pay for electricity and supplies.

8. Retire early.

Most physicians would agree that none of these options are both palatable and practical. Thus, physicians are left wondering how much longer they can be altruistic. When will the medical system display its own altruism towards these physicians?

Only time will tell.

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