Gaming the System

It's always something ... as Gilda Radner on the early Saturday Night Live used to say in her character as Roseanne Roseannadanna. The world, money matters and medicine elusively remain one step ahead of us and we are seemingly always in catch-up-football mode.

— As attention has turned back to the primary care shortage with 30 million new insurees coming to market next year from the Affordable Care Act, it is bracing to learn that the residency match this year for primary care was very strong.

But don't get too excited, a UC Davis study showed that primary care doctors earn an average $2.7 million less over their careers than some of the procedure-based specialists. Not a big selling point when the average graduating resident now carries a $165,000 average debt load into practice.

Let's wait to see what the match brings for the next few years before relaxing.

And Bernie Sanders, the senator from Vermont recently released these stats into the congressional record about primary care:

• The average primary care doctor is 47 years old and a third of them are nearing retirement. Many delayed their retirements due to the recent recession, so expect to see a belated spike in retirements just as the new insurees start clamoring to be seen.

• Only 29% of doctors provide access to care on the evenings, weekends and holidays — ergo, the continuing, and unnecessary, pressure on ERs for routine problems.

In the past, one of the things that made a difference for my organization for continuity of care, marketing for new patients and improving the bottom line was opening early, closing late and being open seven days a week. That's what busy patients want and need.

• A shrinking percentage of the physician population sees the majority of patients. Couple this fact with the onset of ICD-10 next year increasing codes from (only!) 13,000 to 68,000, and we are looking at a paperwork, payment and access crisis.

— Back to more mundane matters; a recent survey in Worth magazine told us that the average person with a high net worth ($10 million) used eight different advisors last year. Finding the first, the best, one is key. A second good advisor may be helpful for a different perspective, but usefulness would seem to drop sharply after that. Then you just get confusion.

— The social media phenomenon is too new to have sorted itself out yet in medical practice. Epocrates reports that 82% of doctors are using social media to interface with other doctors, but only 8% with patients. There are still legal, privacy, fee-billing and a host of other concerns that have to be ironed out.

— EMR/EHRs are now being used by over half of physicians, but the transition has proved to be more costly and cumbersome than anyone foresaw. And the measurable benefits to patient care have proved to be underwhelming thus far. It's another theoretically good idea that has bogged down in the details and the execution. For instance, most of these systems don't talk to each other and there are big financial, and ego, blocks to agreement on a common system that might achieve its promise.

— The Wall Street Journal recently reported that for every person who is buried, four are now cremated. Yes it saves money, especially coming out of a recession, but it also comprises a profound cultural shift that has snuck in under the radar.

— With the mortgage and foreclosure crisis fading behind us, another stat has surfaced showing yet one more advantage that the wealthier among us have had. People with foreclosed loans under $250,000 averaged 611 days before repossession while those with bad loans over $1 million averaged 792 days. That boils down to two years of free rent in a nice home.

I heard a guy call into a local talk show who said that he did the math, stopped paying his mortgage, but put the payments away for two years into a savings account to accumulate a nice down payment on a newly lower valued, but nicer home. Except for the hit to his credit, the Mortgage Meltdown provided him with free money.

Just like in health care, when you have a dysfunctional system, people will find a way to game it to their benefit.