American College of Physicians: Internal Medicine — Doctors for Adults ®

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Monday, December 16, 2013

My deadly reality

Lately I’ve gotten hooked on watching the Discovery Channel’s reality TV show, The Deadliest Catch. lt’s astounding to me what these guys go through to catch crab in the Bering Sea.

One of the recurring themes on the show is the new crop of “Greenhorns,” new recruits to the profession of working crab boats, that try to show they can hack “the world’s most dangerous job” each year. They often come with bravado and brashness, thinking that they can prove to the world just how tough they are. Reality hits quickly, and most greenhorns don’t make it through the year. The more the bravado, the more quickly they seem to wilt.

Welcome to health care 2013: my reality TV show. Here is something my family just got from our insurance company:

$1,200 per month? This is double what we have been paying all along. Compared to this, the $50 per month that I charge (maximum $150 per family) seems pretty reasonable. This plan is, after all a high-deductible insurance that doesn’t cover a whole lot of services, so a practice like mine that focuses on avoiding unnecessary tests, medications, and use of medical services would make a lot of sense, wouldn’t it?

But people are scared and confused by what has been going on with the Affordable Care Act. They are getting letters like this, and (like me) don’t know how they can afford to do this. I have to admit, the irony of this happening as a result of something labeled “affordable” is not lost on me or my patients. It’s also a tough irony to see how a practice like mine, which was built to offer access to truly affordable care, is being hurt by the ACA.

Today I got this from a patient who recently signed up:

I am sorry to inform you that due to our circumstances, and the ACA, it is not feasible for us to use your service. We would still not qualify for appropriate coverage because we don’t have hospitalization. We will just go to prompt care or the Emergency Room if necessary. Actually, I hope everyone drops their health insurance and goes to the emergency room, and show the socialists how we can totally decimate their ideas of forcing some to pay for others. If I didn’t have so many personal issues right now I would have stayed with you, but if I would still be penalized for not being in an exchange, it doesn’t make sense to keep going. Some months we don’t even go to the doctor, so I must say thank you, for your work with us, and I hope you are able to weather the storm, and we wish you success.

While this sentiment is fairly strong, it is fairly representative of people’s feelings on this issue. Other direct care providers have reported a significant drop in the number of people signing up.

The solution, I am told, is to combine what I am doing with a “wrap around” high-deductible plan, and that “will meet the ACA requirements” and get the person out of paying the fine. Many/most of my patients are interested in this possibility, both for themselves and for their businesses (as a very large percentage of my patients are owners of small businesses). This would benefit all parties, it would seem:

This would be a huge gain for me, as it would give my practice an inside-track to a large number of patients.

It would be good for the patients, as it would give them the ability to avoid the fines while maintaining high-quality care.

It would benefit the small businesses as they’d be able to insure their employees or at least be sure their employees weren’t getting socked with huge insurance bills (see above).

It would benefit the insurance companies, as I would be far more focused on avoiding spending up the patient’s deductible, reducing unnecessary testing, and keeping the patient out of the ER/hospital. In short, they would reduce the risk, which is speaking in a language insurance companies know well.

This is where, just like it does to a greenhorn on The Deadliest Catch, reality hits. It’s not as easy as I thought. I thought the contrast of my practice’s simplicity with the complexity and confusion of the ACA would have people seeking alternatives. Enter me stage left with heroic bravado, here to save the health care system! But I am met with the same smirks and sneers thrown at the greenhorns by the weathered deck hands.

None of my patients know what to do, and I could probably get several hundred covered lives’ worth of business for an interested insurer. I could make some employers happy and the lives of a bunch of employees happy as well. But when it gets right down to it, I am met with blank stares. How crazy, wanting to do things in a better way! How crazy, trying to improve care quality while saving money! How crazy trying to offer truly affordable care! Don’t I know that there is no cutting into line here, and that I’ll have to fill out all the proper forms and stand at the end of the line until my turn comes?

I’ll still hit the street and try to get answers for my patients. I’ll still be calling more insurance agents trying to put something together that doesn’t make a mockery of the word “affordable.” But I suspect my hopes for gaining some advantage by the provision in the ACA for pairing practices like mine with wrap-around plans is not reality.

These crab pots are coming back empty.

After taking a year-long hiatus from blogging, Rob Lamberts, MD, ACP Member, returned with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind), where this post originally appeared.

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Blog log

Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:

Albert Fuchs, MD
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.

And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.

Auscultation
Ira S. Nash, MD, FACP, is the senior vice president and executive director of the North Shore-LIJ Medical Group, and a professor of Cardiology and Population Health at Hofstra North Shore-LIJ School of Medicine. He is Board Certified in Internal Medicine and Cardiovascular Diseases and was in the private practice of cardiology before joining the full-time faculty of Massachusetts General Hospital.

Zackary Berger
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.

Controversies in Hospital Infection Prevention
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).

db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.

Suneel Dhand, MD, ACP Member
Suneel Dhand, MD, ACP Member, is a practicing physician in Massachusetts. He has published numerous articles in clinical medicine, covering a wide range of specialty areas including; pulmonology, cardiology, endocrinology, hematology, and infectious disease. He has also authored chapters in the prestigious "5-Minute Clinical Consult" medical textbook. His other clinical interests include quality improvement, hospital safety, hospital utilization, and the use of technology in health care.

DrDialogue
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.

Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.

Everything Health
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.

FutureDocs
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.

Glass Hospital
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.

Gut Check
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.

I'm dok
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.

Informatics Professor
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.

David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.

Just Oncology
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.

KevinMD
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.

MD Whistleblower
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.

Medical Lessons
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.

Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.

More Musings
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).

Prescriptions
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.

Reflections of a Grady Doctor
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.

The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.

Technology in (Medical) Education
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.

Peter A. Lipson, MD
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.

Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.

World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.

Other blogs of note:

American Journal of Medicine
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.

Clinical Correlations
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.

Interact MD
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.

PLoS Blog
The Public Library of Science's open access materials include a blog.

White Coat Rants
One of the most popular anonymous blogs written by an emergency room physician.

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