• More of our primary care physicians are pulling back from hospital work. Some admit but refer all management to specialists whom they call in. Others refer to specialists and ask them to admit. A growing number sign out all hospital calls and coverage to our current pulmonologist-hospitalists.
• More of our specialty physicians are pulling back from hospital work. Many are much busier and more productive in their offices, surgicenters and imaging centers. Hospital call and care is being turned over to junior colleagues or fellows in local training programs.
• Some observers now complain that all of this too often results in inefficiently managed patients. Without someone assuming the ultimate decision-making authority and coordinating consultants’ recommendations, patients can languish in a hospital bed.

• Medicare reimbursements for ancillary procedures financially supporting office practice have been cut sharply in 2007 and will be cut further. Paltry increases in office visit services do not adequately compensate for these cuts.
• PPO insurance reimbursements fall as Medicare rates fall. These contracts peg payments to a percentage of Medicare rates. Blue Shield now pays 60% of a Medicare allowable charge.
• Our governor proposes a 2% tax on gross physician revenue. Imagine an oncology practice with hundreds of thousands of dollars in gross income from chemotherapy with a currently small profit margin. Net income to the oncologist could drop 30%.
• Even more government limitation on physician business practice. 2007 Stark rules further restrict the manner and location of physician imaging services.
• Practice overhead grows relentlessly. Southern California has the highest overhead in the country.
• Practice growth is almost impossible. With our backs to the sea, our marketplace is limited. Recruitment of new physicians in order to grow is next to impossible because of our cost of living.
• Caring for hospitalized patients has become a poor use of an office-based physician’s time. Reimbursements relative to time involved are low. The hassle factor outweighs the professional obligation for many. Fighting with an InterQual computer to get a patient admitted and taking phone calls from discharge planners and hospital administrators wanting a patient discharged becomes too much to take.

• Accepting no new Medicare patients.
• Limiting under 65 new patients to well patient care
• Narrowing the scope of practice--micropractice.
• Employing mid-level practitioners such as PAs and NPs to limit patient time commitment.
• Increasing throughput--shorter visit times
• Limiting office hassles—less telephone access.
• Adding even more ancillaries—DEXA, ultrasound, stress testing.
• Adding “access fees” for uncovered, preventive services.
• Adding cash pay services—botox, laser and skin treatments product sales,
• Doing med-legal work
• Transfering hospital care to junior associates if in group practice.
• Transfering hospital care to “hospitalists” if in solo practice.
• Considering early retirement.

      How does all this affect our private healthcare infrastructure? Primarily in ways which do not benefit our sick patients.

• Fewer physicians available to see new sick patients.
• Less physician time available for sick patient care, more time spent on ancillary procedures and services.
• Less time for interaction among primary physicians and consultants in the care of sick patients.
• Less efficient hospital care by “hospitalists” who have less information about and no relationship with sick patients they admit.
• Deterioration of our physician-patient relationships, loss of loyalty from our patient base, potential loss of our unique marketshare.