I suffer the curse of rumination. I ruminate, overthink, and ruminate some more Strangely, I don’t tend to worry all that much, but I think on things, repeatedly, and often. My ruminations have a tendency to make the simple complex, the joyful a morass of conflicted emotions.
A recent drive home across the Big Empty was fertile grounds for such rumination. I had completed a 78 hour shift on the High Plains. It was an easy shift. I saw 10 clinic patients, 5 ED patients, one of which I admitted to the hospital. None of it was particularly complex nor emergent.
For that amount of work, I made roughly 1/2 the salary that most outpatient family docs make in a month. That is right, for 15 patients, I made about over a 1/3 of my income for the month. You would think I would have been driving back home thinking about how I lucky I am to have found such a gig in modern medicine.
Instead, I became what my wife terms “thinky.” I couldn’t help but feel somewhat guilty. Imposter syndrome quickly followed the guilt. Is someone going to figure this out and get rid of this? What will I do then?
This clearly is not sustainable for the country…Is it sustainable for me?
The Stories We Tell Ourselves
Obviously, from a financial standpoint, I did not generate enough income from my physician fees to justify what I was paid (not to mention what the company I contract with got paid). I generally justify what I get paid with this knowledge:
The hospital pays me to keep the ED open, not to generate revenue.
It is true, of course. And a true free marketeer would simply say, “If someone will pay you to do it, it is the market’s will.” A lot of people don’t want to do what I do, so my willingness to do it is worth a high price.
It may just be that simple.
Nonetheless, I often still feel like a profiteer. My services are expensive. I can’t help but wondering why someone hasn’t figured out how to avoid using me.
Of course, this is not my problem to solve. Plenty of people are paid quite well to manage these little hospitals, and if they can’t figure out a better solution, why does it bother me?
I keep speeding along open highway…
I stare at the prickly poppies in the ditch as they race past fenceposts along the green and tawny plains. I can feel my brain chewing its cud. The anxiety behind the above question is, of course, what will I do if they do figure out something better?
It is a real, yet remote anxiety, I turn down work every month. There is too much need on the High Plains to fill.
How is there still so much work available that I am constantly turning down shifts?
Of course, I know the answer. The High Plains are not for everyone. It is tough country. There are no beaches nor ski resorts to attract and retain doctors like resort towns have.
Moreover, hospitals tend to ask more and more of their staff until they quit. Succession planning is not in the vocabulary. Rural hospitals live from crisis to crisis. Part of this is the natural result of having shallow benches.
If a town only has 3 docs, all it takes is for one one to get sick, retire, quit, get in trouble with the medical board and you are suddenly asking your docs to take every other day call. The call schedule for the rural Emergency Departments is like Jonathon Edward’s God:
The God that holds you over the pit of hell, much as one holds a spider or some loathsome insect over the fire, abhors you, and is dreadfully provoked;
-Jonathon Edwards, Sinners in the Hand of an Angry God
The Rural ED Call Schedule takes but a faintest provocation to throw the lives of its participants into absolute chaos. It only knows how to ask for more. Living, day in, day out, under the guillotine a rural ED call schedule is knowing your kids’ games, family dinners, trips with friends all hang in a delicate balance.
They could all be lost at a moment’s notice.
It is not for the faint of heart. It is also a stress which the non-clinician cannot know. Managers of rural hospitals ignore the psychological effects of living under that cloud at their peril. Unfortunately, most do and turnover is constant.
As long as a cost-based reimbursement continues to be a policy of Medicare, I will have more work than I know what to do with.
Cost-Based Reimbursement, the Lynchpin
I have mentioned cost-based reimbursement before. It is absolutely the only reason Critical Access Hospitals are able to use me and not go broke.
The basic tenet of Cost-Based Reimbursement(CBR) is that for a given hospital stay in a Critical Access Hospital, Medicare will pay 101% of the “cost” of providing services to that patient. Who gets to decide what is included in that cost? The hospital.
So, because my fees can be included in the cost of providing an inpatient stay, they can be written into the CBR formula. Of course, if I am in the ED seeing a bunch of patient’s, this cannot be included in an inpatient cost report.
So, hospitals have to report how much time a physician spent on an admission, rounding, other inpatient tasks. Then, they can roll that percentage of my fee into their cost report and get reimbursed for it.
In short, without cost-based reimbursement, I would likely be out of a job.
Though I am technically a “business” as a 1099 sole proprietor, my entire income hangs on government spending at its root. This is the reality of most of healthcare in this country. Sure, some people have private health insurance, but public healthcare spending is what keeps the lights on around this county’s hospitals.
We would do well not to forget that.
So, is it Sustainable?
I decided to write this post for one reason, to break my rumination cycle. Sometimes, putting thoughts down on the blog helps release them. The reason a cycle keeps going because I have no definitive answer.
Clearly our current healthcare system is unsustainable. Cost-based reimbursement may be as well. However, I am hardly alone in making a very good living off the healthcare system without necessarily adding that much value.
On the other hand, rural locums is common in plenty of other countries with systems less screwed up than ours (New Zealand, Australia, UK, and Canada). So, this might be plenty sustainable. Like every thing else in healthcare, we all know it can’t keep going like this forever, but it might go like this long enough for me to finish my medical career.
I guess this is gig will be sustainable until it isn’t.
Featured Image: Path in the Forest. Spruce Forest. Ivan Shishkin, 1880.