The State of Medicine

Our practice, to my surprise, keeps going in a stable fashion, despite all the changes whirling around us. Medicare has had us register electronically in an incredibly complicated fashion, asking for various identification numbers in a 40 plus page document. Physical exams will apparently be covered for the new year, although at a discounted rate. We shall see how primary care does in the next couple of years. The need is overwhelming, and fewer medical students and residents are choosing the field. I do not know whether all, or any, of the changes legislated in the new health care law will be enacted. The states need to be involved in its implementation, and many so-called red states are not very keen on enabling the process. We shall see.

As always, I am looking forward to seeing and taking care of my patients. January is historically a difficult month. There is the inevitable post-holiday letdown on the part of patients, and the weather typically plays havoc with the commute and with scheduling. I am also looking forward to working with a new set of physician assistant and medical students. Their insights and lectures teach me as much as I teach them.

The Mattress

I don't quite know the irony, if any, in this situation, but on my way home yesterday in bumper to bumper traffic on the Beltway, an abandoned mattress lay on the side of the road. I was quite tired, and I mused that I could have had a snooze while the rush hour traffic thinned out. But, then again, what with the bedbug situation that there is, perhaps lying on that mattress woyld not have been a good idea after all.

The Electronic Life

One clear message that I received during the ACP meeting was the importance of having interoperable (freely communicating) electronic data on patients. We are of course in the midst of the information revolution, which is yielding important new knowledge by our having the ability to "connect the dots" so much more readily. The public health benefits of having such information are very obvious. We can track diseases, pinpoint their nodes of activity, and be able to glean cause and effect connections. With individual care, I feel that benefits can be obtained readily by having treating physicians communicate more effectively with each other by e-mail. Timely reports from consultants and radiologists would be so helpful. E-mail access to laboratory information which we have in the office has been helpful to patients on many occasions.
The need for imposing electronic infrastructure will further cause the decline of the small practice. This is inevitable, despite protestations from IT people in industry and government notwithstanding. We need an integrated medical workplace, alas. Small practice, like the one I have, still has many benefits- personalized care and better continuity of care, for example. In order for it to survive, however, IT costs need to keep dropping. Perhaps the use of the "cloud" for medical information will help. We shall see. I am still bearish on small practice prospects in the long run, however.

American College of Physicians Meeting

I was one among many of the gray hairs that predominated the crowd at the local American College of Physicians (ACP) meeting in Bethesda. Internal Medicine is a beleaguered and changing field, and ACP represents its ideals as an intellectually minded and academically oriented organization. Of course, academics and primary care have been taking bit hits lately, which have had its impacts on the ACP. This year's meeting was limited to one day (it had been two for many years). The discussions and the collegiality were unchanged, thankfully. There was a vibrant discussion on the electronic health record and meaningful use by leaders in the field such as Dr. Peter Basch. And Dr. Sean Whelton of Georgetown sobered up the audience by demonstrating that, while the old timers in the audience had subscriptions to paper newspapers, only one of the medical students he surveyed had one. The younger generation thinks differently in terms of information acquisition, and the old-timers like us need to think about this.
One change that was very hopeful was the participation of woman as a coherent and vibrant group within the organization. They showed up as a large group to the breakfast interest section, were engaged, and were for the most part, younger. This bodes well for the local ACP. The new Governor -elect, Dr. Alice Fuisz, is an excellent physician-leader who will no doubt continue to encourage increasing female participation into what was once a very predominantly male realm.
It was good to see old friends, although I am bit wistful of times gone by. The new medicine will be more group oriented and electronically integrated, with physicians as employees, and hopefully, as managers and leaders of larger organizations.

Getting Rid of Medicaid

The new ascendant Republicans are thinking of all sorts of clever ways to subvert the new health care plan. The one seriously proposed by some in Texas to opt out of the state's Medicaid program is just such a subversion that even I thought serious people would not consider. Medicaid is a combined state and federal program that pays health care costs for the poor, disabled and chronically ill. States differ in their generosity of their respective Medicaid programs, both because of their relative wealth and because of their social priorities. The Feds kick in at least 50% of the total cost, but in some cases (such as in D.C.), provide a much greater portion of the total tab. Red states in the South are not particularly generous to begin with. But getting rid of Medicaid altogether? I know it is a great cost savings (and a potential boon to the funeral industry). How about getting rid of the mandatory public school system? That would save a lot of costs too. Taxes would go down dramatically. And think of all you could do with that extra money. Come to think of it, the extra money would go to propping up drowning hospital systems managing newly uninsured patients and making all those private school tuitions.
The proponents of getting rid of Medicaid say that such patients would be part of the health care pools set up by the new health care law, so, no muss, no fuss. Right. Those health care pools, with their mandatory requirements to sign up for health insurance, are going to fought by those same anti-Medicaid Republicans.
My faith in the ability of the new health care law to positively affect the ills of our health care system go down day by day.

Primary Care

The practice of Internal Medicine, a type of primary care, has been a tricky financial trick to pull off in a small private practice setting in the last few years. The flat reimbursement rates, the increasing involvement of insurance in the personal management of medicine, and the new and evolving unfunded mandates from the government have conspired to make a successful go of it a challenge. The stimulus package from 2009 included the so-called Hi-Tech act, which incentivizes practices to use electronic health records (EHR), and more ominously, de-incentivizes practices after 2015 for not using such EHRs. The trend in medicine has been to integrate practices, either in group practice settings, or as alignments with hospitals.
Yet, despite all of this, the practice of medicine in a small setting continues to have its satisfying moments. I have good and important relationships with patients and their families, and I still feel that I have the ability to do good in a personalized way.
But, who am I kidding, the future does not bode exactly well. The trend line is still going down. And there is a new scare looming ahead that threatens to unravel the whole financial viability of such practices. SGR is an acronym describing the need for the Medicare program to square costs with reimbursements. According to the Balanced Budget Act of 1997, if Medicare costs go higher than the rate of inflation, those costs need to be recouped by decreased physician reimbursements. Now, mind you, these are total costs. So, if too many CT scans or MRIs are done, primary care physicians suffer as much as the radiologists. Because of the inherent concerns with decreasing doctor reimbursements (namely, that physicians would therefore leave the Medicare program en-masse), Congress has always decided to forgo the SGR adjustments and keep physician reimbursements where they are, occasionally even adjusting upwards for inflation. As these adjustments are not made, the bill for future adjustments keeps going up. Right now, if fixes are not made to the SGR, physician reimbursements are set to go down by 23%! in December.
Now here is the problem. If the lame duck session of Congress does not make a fix to the SGR, it will be left to the new Congress. You know, the Congress with all the new tea party members who are concerned with deficit spending. They may make an example of SGR, sticking it to the doctors taking care of Medicare patients.
If they do, I feel that the private practice of medicine will suffer a significant body blow from which it may not recover. And primary care will suffer the most. This, despite the fact that the new health care law did make an attempt to increase primary care pay.
The small practice is the example of a dying business, like the vacuum tube industry of old. There may be a small niche for it, but how long it lasts ill be unclear.

Post Mortems

So I have been commiserating with my Democratic patients about the election results. I have got to hand it to Nate Silver at Five Thirty Eight; except for the Harry Reid win in Nevada, he nailed all the numbers. Something about the proper use of probabilities and math. He does it right. Unfortunately the results are dispiriting to a liberal like myself.
What is with the Midwest? How did they go Republican? The Democrats pushed through the auto bailout, which saved many hundreds of thousands of jobs. Most of the money given out by the feds has already been returned. GM went public with an IPO this week. The Dems voted, in the face of Republican disapproval, the continued extension of unemployment insurance. If there is a region in the country that needs the help of good government, it is the Midwest. So, what gives?
I am happy that at least the most "out there" tea partiers like Christine O'Donnell and Sharron Angle did not win. But we still get Rand Paul and Mark Rubio. They will intone about the deficit, lowering taxes, and helping people find jobs.
I am ready for the new non-sequiturs of this Congress.