Seattle PI Opinion Piece by nephrologist who has opted out of all insurance

[Guest guest]

Posted earlier on AAFP Pract Mgt list.

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http://seattlepi.nwsource.com/opinion/388903_smiley23.html

Why the doctor can't see you nowBy S. SMILEY THAKUR - GUEST COLUMNIST --------------------------------------

As someone pointed out, while the article is interesting and brings up the frustrations with the current insurance system (although not all will agree with every statement in the opinion piece), the real fascination is with the nerve that was nicked with readers/patients.

See the link for these comments below.

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My favorite comment is -- "I can't believe people would argue with free comprehensive health care"

I certainly wouldn't argue against it -- no more than I would argue against free housing, free food, free transportation, free et al.

What I find most interesting is the obvious frustration with health care --- which probably bodes well or naught (depending on your view) for the next administration to make major changes in how health care is delivered in the US.

I thought is was interesting that people were railing against the article despite the fact that Dr. Thakur was seemingly aruging for...

Less interference between the doctor/patient relationship

Less overhead -- and lower costs

Seeing the patient on time due to the need to see less patients

Calling patients back and filling their refills promptly

Who could be against that?

I would have hoped that the respondents would have said something more like -- why yes, Dr. Thakur, we agree with all your points -- but we feel that a nationalized healthcare system can deliver these same services -- or something along those lines.

Instead, it got personal very quickly...again, I think that is frustration with the current healthcare system bubbling over...IMHO.

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Of note, here is Dr. Thakur's office website...

http://www.kidney.nu/

HOW WE BILLThis is a self-pay practice. We require patients pay in full at the end of each visit. • I am an out-of network physician.• I am not a preferred provider for any insurance plan.• I am not a Medicare provider.• I do not bill insurances but supply you with the appropriate receipt and information for reimbursement.

FEE SCHEDULE$360 Initial Consultation (~1hr)$270 Follow up Evaluation - Complicated (<45 min or 5-8 problems)$180 Follow up Evaluation - Routine (<30 min or 3-5 problems)$90 Follow up Evaluation - Basic (<15 min or 1-2 problems)

$50 Phone Management (<10 min)$100 Phone Management (<20 min) $150 Dialysis Management (per month)$100 Late Cancellation FeeHouse calls are offered for an additional $200 to established patients, during business hours

At first, it looks expensive -- but when you think about it -- most probably charge $60-110 per 99213 and see 3-4 patients per hour.

So are billing (not netting, but billing) $180-$440/hour.

He's not that far out of the ballpark, it wouldn't seem.

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Considering some of the patients complained about waiting a long time to see their doctor and getting charged $200....why wouldn't they be supportive of this doc's practice...he promises to...

http://www.kidney.nu/difference.html

ON-TIME APPOINTMENTS Dr. Thakur values your time. In his nine years in practice, he's managed to stick closely to the appointment schedule. If your appointment is at 10:30, that's when you'll be seen. His patients love this reliability of service. If he's going to be a few minutes late, we let you know when you arrive.

PHONE CALLS ARE RETURNEDDr. Thakur appreciates that some matters can be taken care of by phone. All messages will be seen by Dr. Thakur within one hour and you will hear back from either him or his staff shortly. Dr. Thakur values your contacting him. He and his staff know all calls deserve a reply.

PROMPT APPOINTMENT BOOKINGSometimes you need to be seen now. Dr. Thakur has always kept room in the schedule for patients who need to be seen urgently. This has been a great comfort to anxious patients and concerned physicians who request early evaluations.

PRESCRIPTION RENEWALSOur office manages over 200 incoming faxes daily. We promptly reply to faxes from pharmacies, labs, and other physician offices. Staff ensure all faxes are replied to by the end of the day, usually much quicker.

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Surf here for comments...

http://seattlepi.nwsource.com/soundoff/comment.asp?articleID=388903

There are some PO'd people out there that definitely don't want to hear about how rough it is for docs.

Just a sampling...

Posted by cfj3 at 11/21/08 3:12 p.m.

"Insurers must stop interceding in the doctor-patient relationship. Insurers add nothing beneficial to this interaction. In medical terms, they are a parasite."- Most large insurers have programs to alert doctors and/or patients when drugs are prescribed that have the potential for a dangerous drug-drug reaction. In all cases that I am familiar with, the alerts are only informative and are often ignored. Many doctors are prescribing large numbers of potentially harmful drugs. It is common for Medicare members to be on 8 to 10 prescription drugs at a time.Now, tell me again, how insurers add no value, and are merely parasites?

Posted by Onyotaka Lukwe at 11/21/08 5:34 p.m.

Well, many people get into medicine to get wealthy, period, even though at the start, the name of the game is to convince admissions that you want to "help" people. And some are truly genuine in that goal. But, later, between the horrific student loan debts, the malpractice isurance, the cost of hanging up your own shingle, etc, and the reality of taking in patients whom reimburse at half the cost of running the clinic, it's pretty easy to see why it can be a pretty bad experience, and it's clearly reflected in the profession's "among the highest" divorce and suicide rates. Particularly, new Doctors are to be sympathized with. But. It is the profession-- and one has to wonder if it's worthwhile for the State to subsidize public medical schools if the graduates won't reciprocate by answering the State's needs. Do only the rich deserve a transplanted kidney? Should economic status determine social worth, who lives, who dies? Why should there be quality grades of health care, in practice, medical eugenics in a democratic society?

Posted by US at 11/22/08 8:30 a.m.

I will exchange income with you, Dr. Thakur. You seem to assume all patients can afford $200 to wait 3 hours in your waiting room. I think doctors lose touch with the real world, and don't realize that the middle class is extinct. I guess the good doctor wants just a handful of rich doctors to treat the handful of rich folks that are left. ( my brother is an electrical contractor working on a $6 million dollar home for a physician. He says the majority of expensive homes are built by physicians. Look in the recorders office and see who owns most of the property in town-physicians or dentists.)

Posted by markit8 at 11/22/08 11:06 a.m.

I don't know of any doctors that are trying to balance home and worklife. Usually, the doctor's dilemma is choosing between Jamaica and Belize for the next scuba vacation, or which to buy the Mrs. for Christmas: The Audi or the Lexus? Tough choices.

Posted by waggingitseattle at 11/22/08 11:00 p.m.

Doctors closed down medical schools 10 years ago to reduce supply.Debt-funded education is a way to turn doctors into debt-burdened fanatical capitalists when they enter practice.

snip/snip

Posted by jem1 at 11/23/08 1:35 a.m.

Just another example of illogical premises, followed by inane questions offering no logical solutions. Raging against Medicare as if the health care system was perfect before the Medicare creation. Medicare came into being because senior citizens were being gouged by the medical profession for every last penny in their meager savings. The fees had to be restricted because the doctors were gouging both the Medicare system and adding on fees to the patients beyond the Medicare payments. All of the situations and solutions listed in this column would apply to General Practitioners of which this specialist is not one. A transplant nephrologist deals with specialized kidney operations, one of the highest paid professions within the physician field. Just another hardcore, conservative, Republican doctor claiming the superiority of the "free market" system in health care. Just as phony as the bill of goods sold by the financial industry for the last 30 years. Nothing in this diatribe offers any real solution for anyone except those who are rich enough to pay the exorbitant rates expected by these "superior" professionals. All of the increases in charges and fees in the entire healthcare system have been instituted by the people in the system. Patients have no control, and the only restriction is through Medicare. The system charges the maximum that the present market will bear which is capitalism to the nth degree without any real government oversight. Any patients who fail to pay their bills are dunned into bankruptcy. The entire system is run by the doctors and professional managers in insurance, HMO, and drug monopolies as private enterprises. Any controls are voluntary through their own groups, i.e., AMA, AHA, etc. The only real government regulation comes in Medicare and Medicaid. All others are completely unregulated(the FDA is staffed by drug company sycophants). Congress just wrings its collective hands and cries, "What to do? What to do?" Every doctor or doctor group who refuses to accept medicare patients should lose their licenses to practice. They won't go broke; they just won't be able to buy that new, tax-deductible Hummer.

Posted by samdinista at 11/23/08 10:40 a.m.

Dr. Thakur would like to see a Ayn Rand influenced medical system in which the wealthy have the ability to pay him what ever he deems to be a reasonable amount for his services, while everyone else dies. Dr. Thakur should, perhaps, do us all a favor and retire.A far more informative article appeared in today's Washington Post;5 Myths About Our Ailing Health-Care SystemBy Brownlee and Ezekiel EmanuelSunday, November 23, 2008; B03With Congress ready to spend $700 billion to prop up the U.S. economy, enacting health-care reform may seem about as likely as the Dow hitting 10,000 again before the end of the year. But it may be more doable than you think, provided we dispel a few myths about how health care works and how much reform Americans are willing to stomach.1. America has the best health care in the world.Let's bury this one once and for all. The United States is No. 1 in only one sense: the amount we shell out for health care. We have the most expensive system in the world per capita, but we lag behind many developed countries on virtually every health statistic you can name. Life expectancy at birth? We rank near the bottom of countries in the Organization for Economic ation and Development, just ahead of Cuba and way behind Japan, France, Italy, Sweden and Canada, countries whose governments (gasp!) pay for the lion's share of health care. Infant mortality in the United States is 6.8 per 1,000 births, more than twice as high as in Japan, Norway and Sweden and worse than in Poland and Hungary. We're doing a better job than most on reducing smoking rates, but our obesity epidemic is out of control, our death rate from prostate cancer is only slightly lower than the United Kingdom's, and in at least one study, American heart attack patients did no better than Swedish patients, even though the Americans got twice as many high-tech treatments.Moreover, the quality of health care is different in different parts of the country. The Centers for Medicare and Medicaid Services have issued a list of 26 measures of quality, such as making sure that heart-attack patients being discharged from the hospital get a prescription for a beta blocker or aspirin to help reduce the risk of a second attack. It turns out that quality is all over the map, and it isn't necessarily better in the places we might expect, such as academic medical centers. Worse still, according to the Congressional Budget Office (CBO), there appears to be no connection between how much Medicare and other payers spend on patients in different parts of the country and the quality of the care the patients receive. You are no more likely to get that beta blocker or aspirin in Los Angeles than in Portland, even though Medicare spends twice as much per beneficiary in Los Angeles.2. Somebody else is paying for your health insurance.Nope. Even when your employer offers coverage, he isn't reaching into his own pocket to cover you and your fellow employees; he's reaching into your pocket, paying you lower wages than he would if he didn't have to pay for your health insurance.Rising health-care costs are partly to blame for stagnant wages. Over the past five years, health insurance premiums have risen 5.5 times faster on average than inflation, 2.3 times faster than business income and four times faster than workers' earnings. Four times. That's why wages have been nearly flat since the 1980s, even as U.S. productivity has been going up. In effect, about half the money you should be earning for being more productive is being sucked up by ever more expensive health-insurance premiums.If you pay taxes, you're also paying for the health care provided through state and federal programs such as Medicare, Medicaid, the Veterans Administration and the military. All told, the average family of four is coughing up $29,000 a year for health care through taxes, lower wages and out-of-pocket medical expenses.3. We would save a lot if we could cut the administrative waste of private insurance.The idea that we could wring billions of dollars in savings this way is seductive, but it wouldn't really accomplish that much. For one thing, some administrative costs are not only necessary but beneficial. Following heart-attack or cancer patients to see which interventions work best is an administrative cost, but it's also invaluable if you want to improve care. Tracking the rate of heart attacks from drugs such as Avandia is key to ensuring safe pharmaceuticals.Let's just say that we could wave a magic wand and cut private insurers' overhead by half, to what the Canadian government spends on administering its health-care system -- 15 percent. How much would we save? Not as much as you may think. Private insurers pay a little more than a third of what we spend on health care, which means that we'd cut a little more than 5 percent from our total budget, or about $124 billion. That's not peanuts, but it's not even enough to cover everybody who's currently uninsured.More to the point, we only get to save it once. That's because administrative waste isn't what's driving health-care costs up faster than inflation. Most of the relentless rise can be attributed to the expansion of hospitals and other health-care sectors and the rapid adoption of expensive new technologies -- new drugs, devices, tests and procedures. Unfortunately, only a fraction of all that new stuff offers dramatically better outcomes. If we're worried about costs, we have to ask whether a $55,000 drug that prolongs the lives of lung cancer patients for an average of a few weeks is really worth it. Unless we find a cure for our addiction to the new but not necessarily improved, our national medical bill will continue to skyrocket, regardless of how efficient insurance companies become.4. Health-care reform is going to cost a bundle.Only if you think that covering the uninsured is our only priority. Yes, making health care available to all citizens is the right thing to do. But it isn't the only thing to do. We also have to fix the spectacularly wasteful and expensive way doctors and hospitals deliver care.Our physicians are working within a truly dysfunctional, often chaotic system that prevents them from caring for us properly. Between 50,000 and 100,000 patients die each year from preventable medical errors. According to the Centers for Disease Control, 1.7 million Americans acquire an infection while in the hospital and nearly 100,000 of them die from it. Laboratory imaging tests are routinely repeated because the originals can't be found. Patients with such chronic illnesses as heart failure and diabetes land in the hospital because their physicians fail to monitor their condition. When patients have multiple doctors, there's often nobody keeping track of the different medications, tests and treatments each one prescribes.Our doctors and hospitals are failing to provide us with care we need while delivering a staggering amount that we don't need. Current estimates suggest that as much as 20 to 30 percent of what we spend, or about $500 billion, goes toward useless, potentially harmful care.There are two bright spots. One: We can improve the quality of care and cut costs without rationing. There are models out there for how to do it right -- the Mayo Clinic, the Geisinger Clinic in Pennsylvania, the Cleveland Clinic and California's Kaiser Permanente are just a few of the organized group practices that are doing a better job for less. Their doctors are better than average at using the best medical evidence available. They're more likely to be using electronic medical records, which can help keep track of patients who have multiple physicians and need complex care. And they're less likely to provide unnecessary care.Two: Even moderate reform of the delivery system would improve care and save money. The Lewin Group's analysis shows that a bill proposed by Sen. Ron Wyden, an Oregon Democrat, calling for a more comprehensive overhaul of the health-care system than either McCain's plan or Obama's could actually insure everyone and save $1.4 trillion over 10 years. More reform is cheaper.5. Americans aren't ready for a major overhaul of the health-care system.We may be readier than you think. A recent study published in the New England Journal of Medicine found that only 7 percent of Americans rate our health-care system excellent. Nearly 40 percent consider it poor. A whopping 70 percent believe it needs major changes, if not a complete overhaul.Now is not the time to think small, to cover a few million Americans and leave the bigger job of controlling costs and improving quality for another day. We can't afford not to reform the delivery system as soon as possible. At 17 percent of gross domestic product, health care is the biggest single sector of the economy, and it's consuming a larger and larger proportion every year. According to CBO projections, health care will account for 25 percent of GDP by 2025 and 49 percent by 2082. That's simply unsustainable. Any plan that reforms health care has to do more than simply cover the uninsured. The nation's health and wealth depend on it.

Posted by serial catowner at 11/23/08 11:30 a.m.

This article is so full of lies and misinformation that people should be mad at the P-I for publishing it.For example, Dr. Thakur tells us he will not see patients with Medicare of private insurance so that he can "preserve patient access to quality care". What he means is that he's not going to see any patients. He's already made enough money treating Medicare and insured patients that, after only ten years of working, he can retire and spend his time writing propaganda.How do I know this? Well, ask yourself how many people in Puget Sound have a million dollars in cash to pay for a kidney transplant. Now, of those people with a million dollars in cash, how many of them would not also have a health insurance policy? That's right- NONE OF THEM. When Dr. Thakur tells these people he won't accept their insurance, they will smile politely and arrange to see some other doctor who will.As another example of Thakur's lying, in one paragraph he tells us about a big doctor shortage, and, in the very next paragraph tells us that doctors aren't allowed to organize into associations.But the reason we have a doctor shortage is because, in the 80s and 90s, the AMA restricted the number of students that would be allowed to enter med schools. They told us that if we graduated too many doctors, none of them would be able to make enough money to make it worthwhile to them to work as doctors. That's the AMA, an association so monolithic that even where young doctors are in the majority, they can't get change past the oligarchy that rules the AMA and much of American medicine.Now, if the P-I had published totally excellent commentaries on our health care systems, and this 'op-ed' column was just a way for us to test what we have learned, it would be one thing. That's not what happened.The P-I has spent their time publishing stories about cats in trees and uses their editorial page to push rightwing propaganda. I've got better papers lining the kitty litter box. The P-I should grow up, or the P-I staffers should start planning for their next job. Just that simple.

Posted by tensharp at 11/23/08 4:11 p.m.

I can't believe people would argue with free comprehensive health care. Unbelievable. Why do you continue to vote against your own interests?

Posted by mhmiller48 at 11/23/08 5:28 p.m.

Physicians should all be salaried and all make the same amount of money (far less than what they make now) and be provided with a decent retirement. That will assure that the people we attract into medicine are interested in and dedicated to the care of patients, that the distribution of physicians is much closer to what we really need and that they have time to spend with their patients rather than their brokers. We should fund their schooling so they don't have huge debts to worry about and can get about their calling. The sooner we take the profit motive out of health care the better off both patients and providers will be.