My family doctor, Dr. Kramer, emigrated to the U.S. from Canada years ago. He has just installed an Electronic Medical Record (EMR) and qualified easily for meaningful use stimulus funds because he takes Medicaid patients. To qualify for meaningful use -- which means using the technology in ways that can be measured significantly in quality and in quantity -- under Medicaid, all you have to do is order the EMR; it doesn't even have to be up and running.
Medicare is more rigid; outcomes must be reported. To report on outcomes, Dr. Kramer had to buy another module of the EMR, probably because the EMR he bought was developed before the meaningful use standard or the stimulus money. In his opinion, it will be difficult to report significant outcomes for Medicare and Medicaid patients, because they often don't stay in his practice long enough. They move, they change insurance, they drop off Medicaid into the ranks of the uninsured.
People in the U.S. no longer stay with a medical practice long enough for longitudinal study -- which is why all our EMRs have to talk to each other and we have to track patients as they move from provider to provider.
As part of a wide-ranging discussion on the state of health care in America, Dr. Kramer told me a little about his experience and that of his family in Canada. He says America does not look at Canadian health care from the right perspective. We think it's great that Canadians have universal health care, but we don't understand what that means.
When he practiced in Montreal, and today, primary care docs were capped at a certain number of billable dollars and patients a month. After he hit the cap, which he did very early in every month, he was only paid 25 per cent of what he billed. His colleagues would limit the number of patients they saw a day to about 20, so they hit the cap at the end of the month.
Dr. Kramer liked to see 30-40 patients a day, so he would hit the cap way before the end of the month, and he wanted to continue to see patients because he enjoyed them. But he finally figured out that it cost him 35 per cent of what he billed to run his practice, so it didn't pay for him to see more patients. He left Canada.
In Canada, the untold story is that although they are insured, 300,000 people are without a primary care doctor, because no matter how many doctors there are, it won't be enough if they have to limit the number of appointments they can grant a month. He told me that's why people in Canada, including his own mother, have to wait two months for an appointment with a family doctor unless it's a real emergency.
I knew that was true of specialists, but I had never heard it about primary care scarcity before. Canadians also pay out of pocket for things like camp physicals; there's a chart of services and costs on the wall of the doctor's office that tells patients what the government doesn't pay for, and what the cost to them will be.
Dr. Kramer loves America because in his own practice he can now happily afford to see 30-40 patients a day. And unlike many family doctors, he continues to see Medicaid patients, even though they pay less, because they are interesting cases. That energizes him; he has problems he can solve.
But he watches the younger docs go on salary and limit themselves to 20 patients a day at places like the Mayo Clinic, and it worries him for the future of American health care. Dr. Kramer admits that it's a great improvement in the physician's quality of life, but he predicts a huge upcoming shortage of doctors as American docs go on a system more similar to that of Canada, and begin limiting the number of patients they see daily because they are no longer incentivized to see more.
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A thorough physical exam and history take time decreasing the physician's income but saving the system megadollars.
Some doctors will only treat one problem per visit which means multiple visits for people with complex health issues; that is, IF they can find a physician willing to take them on.
Medical education is susidized by the taxpayers and a medical degrree is not an atomatic license to print money at the expense of the rest of us.
"People in the U.S. no longer stay with a medical practice long enough for longitudinal study". Yeh,because of all the above--- and it is also hard to ask dead people who their caregiver is.
I have lived under both systems. I laughed at Michael Moore's "Sicko" until we had our own experience. When one is diagnosed, even the best insurance company ( to which you have given the key to your bank account) will try several ways of cancelling your insurance. One is sending you a bill to a nonexistent address for less than $10, then unilaterally cancelling for nonpayment.
No more of that, thanks.
The issue with the US system is the pandering to private insurance companies and the lack of universal availability. Doctors make a good living in Canada. They don't need to become millionaires. I would be suspicious of a doctor who only was in it for the money.
http://www.justicepartyusa.net/
I've been to doctors who watch the clock and rush me through. No, thanks. It takes time for doctors to get to know patients and detect when something is wrong, even if the patient isn't clear about it themselves.
At my doctor's clinic, they set aside the first two hours every morning for people who need to see a doctor that day. The rest of the day is for regular appointment times. I never wait more than a few days to see my own doctor, unless she's on vacation, and in the worst case scenario, I can see another doctor in the practice.
Seems to me the reason there aren't enough doctors is because there's a cap on giving out practice numbers, and therefore on med schools accepting students. A lot of capable students are turned away because they're not in the top 10%. I know some of them, and if they're below the top 10%, I'd be perfectly okay with a doctor in the top 15 or 20%.
In fact, pretty much all my friends and family I have talked to, even those who really like their doctor, talk less about booking months in advance and instead all complain about having to wait for lengthy times even WITH an appointment. Clearly this is caused by doctors over-booking themselves even with limits in place.
The second complaint I often hear is from people unhappy with their doctor. Their complaint is doctors trying to get them in and out as quickly as possible, often resulting in sub-par care, misdiagnosis and more visits. The doctor barely even looks at them let alone recognizes or remembers them or their problem...evne with a file in front of them. Again, what is the cause of this if not doctors trying to cram in as many patients as possible on any given day?
To say we would all be better off it they could take MORE patients makes no sense. Seems to me the only thing this will help is the doctors personal profits.
As to time, I just pray that nobody I know is rushed to hospital with an emergency, only to be treated by a doctor or nurse who hasn't slept for the last 20 hours, who has been running around making life and death dicisions for the last 12 or 16 or even 20 hours. Color me selfish, but I want somebody who is fresh, wide awake and alert to treat me.