Retail clinics are bad news for primary care

Regarding “Doctors should cooperate, not compete, with retail clinics” (March 10, 2016): Yet another assault against primary care as well as specialists. 

One major downside of these “doc-in-a-box” joints is that they skim off the easy and straightforward patients and cases and leave the difficult and time-consuming patients for the good ol’ primary care doc to deal with. 

Why is that bad? Because one can get burned out fast if your whole work day is nothing but  difficult and lengthy cases without some simple cases to break things up.

It’s just more bad news for physicians. Every change that we see is detrimental for us. We are constantly having ever-increasing rules, regulations, and mandates foisted upon us in the name of “patient safety” and 
“quality.”  When oh when are physicians going to finally stand up and refuse to cooperate?  Not soon enough...

David W. Allison, MD

Gainesville, VirginiA

Providers and patients: too many degrees of separation

The federal government has been trying to control the health of citizens for nearly a century, increasingly separating patients and their physicians.

The first degree of separation: World War II wage controls firmly established health insurance as an employee “benefit” in lieu of salary. This gave the employer power to choose coverage based on its needs, not the employee’s. Since World War II, government has imposed a multitude of programs that add degrees of separation: Medicare, Medicaid, Nixon’s HMO Act, ACA and MACRA are only a few examples.

The second degree of separation: Empowered by these programs, insurance companies profit by denying payment for care. Claim denials are often arbitrary decisions leaving patients on the hook despite already paying premiums.

The third degree of separation: Third party payers perpetrate an absurd, inflated retail “chargemaster” price structure. Actual payments physicians receive from insurers are even more guarded. Patients are not made aware of costs prior to care and it they ask are denied information, or are simply billed the chargemaster.

The fourth degree of separation: Physicians and facilities who participate in insurer networks are forced to accept payment rules like prior authorizations and study precertifications.  

The fifth degree of separation: ACA spawned ACOs. These HMOs on steroids are financially encouraged to ration care. Physicians are being pushed into employment for ACOs becoming financial gatekeepers. This violates individual patient’s best interests.

The sixth degree of separation: The government created an epidemic of insurer and hospital consolidation leading to less patient choice and higher costs as meaningful competition fades into the past.

There are solutions to achieve zero degrees of separation between patient and physician:

Medicaid yields little benefit as billions of taxpayer dollars flow into the pockets of companies administering it. Charity should be a local, person-to-person concept, not a government to bureaucrat to HMO concept.

You don’t need to imagine patients shopping for care by quality and price. It’s already happening in a burgeoning free market medicine movement. Patients and physicians cooperate in a plethora of mutually beneficial ways, including Direct Primary Care, bundled cash surgery packages, and fee-for-service care.

True insurance is an inexpensive tool to curb catastrophic financial loss. But government regulations prevents its sale and we are left with junk plans with narrow networks that are more expensive than ever. There should be as many health insurance options as the industry can dream and patients will support.

Health Savings Accounts allow patients to save for medical care and must be expanded to encourage responsibility and respect for preventive healthcare.

Government programs create more scarcity, dependency, and despondency. Let’s remove the layers of bureaucracy that delay, deny and raise the cost of care. Strip away the partisan politics that have destroyed the patient-physician healing relationship and restore it to it’s sacrosanct status. Taxpayer independence, physician independence and patient lives depend on it.

Craig M. Wax, DO

Mullica Hill, New Jersey

Doctors must unite to take back control of medicine

Regarding “MOC recertifications are ‘cancers’ doctors should rally against” (Online, March 5, 2016): The aged, the poor and veterans are already covered under government  plans which are the highest risk groups to insure, so only the working young  and their families are left.

The AMA used to be one of the most powerful “unions” in America-the failing is not government or insurance but our inability as physicians to unite to confront those who have taken the control of medicine away.

Until we can follow our forefathers’ guidance of “out of many, one” or “united we stand, divided we fall” they will continue to pick us off one by one. Perhaps we need to copy the staff of Aesculapius and put it on a flag and write “Don’t tread on me!”

Robert D. Jones, MD

Phoenix, Arizona

ABMS has lost touch with members

Follow the money. I’m from Chicago and I know an extortion racket when I see one. However, the old Chicago Mafia would never treat physicians like the ABMS racket is treating us.

The American Board of Pediatrics replaced its multimillionaire director James Stockman with someone who sends out kindly emails, yet I’m sure his take home pay is triple what mine is. ABP moved its headquarters out of cold Chicago to North Carolina; they didn’t say how many millions that cost.

When I passed my last ABP recertification and was told I would have to participate in MOC, I wrote to them about the fact that being a locum tenens physician and having a disability made it impossible to afford the costs and complete the clinical part, which is based on the now outdated institution of private pediatricians following their own patients. I wrote to them again last year, but all I got in response was a letter in February saying that my ABP certification had expired in December.

Part of these ABMS leaders’ problems in dealing with the horror of MOC is that they are completely out of touch with the practicing American physician, yet still think they are doing something to help people. This delusion is unfortunately very common today in all aspects of academia and government.

The American Academy of Pediatrics is particularly filled with brainwashed advocates of big government medicine to the point that they promote junk science that is politically correct and have forgotten their role as an advocate for children. I remember some medical school professors claiming they saved patients from the “LMD,” which means that they thought all private physicians were quacks and needed to be controlled by them. 

The ABMS and academic physicians need to read the modern version of the Hippocratic Oath and understand why they are in violation of this ancient pledge.

Nancy Henning Weres, MD

Hesperia, California

Quality metrics force unethical choices 

In “Quality metrics: A payer’s perspective,” (March 10, 2016) Jeffrey Bendix states: “A doctor might genuinely believe, for example, that he or she orders mammograms for all patients who need them according to the latest  guidelines.” 

Yet frequently, the “latest guidelines,” are either obsolete or based on poor-quality evidence. Another (major) problem is that guidelines rarely take patient preferences into account.

Mammograms are a perfect example. As  stated by Dartmouth’s H. Gilbert Welch, MD, MPH, “half [of women state] they would not choose to start screening if [mammograms] resulted in more than one overtreated person per one cancer death averted.....that implies that millions of Americans might choose not to be screened if they knew the whole story - that overtreatment is typically more common than avoiding a cancer death.”

Healthcare “quality incentives” are unethical. They often force doctors to choose between implementing the incentivized measure or doing what is in the patient’s best interest. Dr. Salmon might want to review the Hippocratic Oath.

Peter C Cook, MD, MPH 

Lee, New Hampshire