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Parable of the Pizza Shop

One day a man decided to open a pizza shop.  The first week he sold pizzas, collected money from his customers; the happy customers ate hot pizza and business was good.

The next week many of his customers who came in had pizza insurance, and had already paid Blue Wall Insurance for their pizzas.  Since so many of his customers had purchased pizza insurance, the man signed a contract with Blue Wall agreeing to discount his pizzas in return for a larger volume of customers.  And so it went with United Pizza Insurance, PizzaNet and Pizzaetna.  

Pretty soon the man started having trouble getting the pizza insurance companies to pay for the pizzas he sold, and he had to wait a few months for his payment.  They also started meddling with his cooking and trying to dictate what toppings he could use.  They even restricted the use of some of the more expensive ingredients.  He had to hire extra employees to fill out forms and paperwork they required before they would reimburse him.  This all cos…
Recent posts
California's Managed Care Medi-Cal
I thought if I wrote about  “Medi-Cal Managed Care” that my readership may run screaming in the opposite direction.  But hey, what is life without risk?  Anyway, look at this--you’re still here.  Kudos to you for your determination and tenacity.  Here we go:  

In 2013 California decided to change the way Medi-Cal reimburses primary care providers from fee for service to capitation1,2.  Lots of private insurance Health Maintenance Organizations (HMO’s) also reimburse under this model.  For those of you lucky enough not to understand capitation, here’s the quick and dirty:  Traditionally physicians have been paid a set amount for each service rendered:  aptly named fee-for service. Under capitation, a physician is assigned a number of patients and gets paid a monthly fee, generally a few dollars per patient per month (PPPM), regardless of whether the patient receives services or not.  In theory, this is supposed to motivate physicians to ke…

The Slow Demise of the Private Office

Doctors have been bemoaning changes in the practice of medicine for years, and with good reason.  It’s harder and harder to make a go of it in private practice.  In recent years our area has lost several small practices -- Hal Grotke’s Redwood Family Practice closed*, Dr. Garcia retired, Teresa Marshall’s solo office shut its doors, Eureka Internal Medicine transitioned to Humboldt Medical Specialists (which then became St. Joseph Hospital Medical Group), and  Beverly Copeland relocated to Ashland.  As I was writing this, Dr. Windham announced that he is ceasing the provision of primary care at his small office.  Unfortunately, young, freshly trained physicians are not arriving here to take their places.  Most recent graduates take positions with large organizations that can offer loan repayment funds, regular hours and steady salary. It’s no wonder new physicians want to be employees with reasonable pay and limited hours.  If you are not working for yourself, there is no reason to be…

Quality Improvement--or is it?


Who says the quality of medicine needs improvement?  According to some, we have the best health care in the world.  What could we possibly do better?  Do you suppose that during the 11 years of medical training I received, the focus was on giving substandard care?  And besides, how do the health care wonks know that what they suggest will improve upon what we are already doing?  Did anyone think to ask those of us providing primary care if we want to do this, or have time to participate in these protracted projects?  No!  However, let’s give the policy makers the benefit of the doubt, and suppose that primary care does need quality improvement.  Common sense would dictate that no one does anything perfectly and that we all can find ways to improve.  
The world of QI is not a pretty picture.  First off, it seems as though everyone and their grandmother has some QI program that physicians are expected to implement.   These programs are all different, a…


May 2016 editorial
PHYSICIAN BURNOUT--updated version

Medicine:  “Oh, Physician, How do I stress you?  Let me count the ways:”
11-13 years of intense training under immersion in the “Superman” medical culture Sleep deprivation/interruption Emotional impact of treating serious illness, death, or chronic disability Pressure to work while pregnant/sick/chronically ill Malpractice lawsuits Financial debt EHR/ data entry Federal mandates Insurance hassles Isolation Pay for Performance programs and surveys Repetitive work Pressure to see large volumes of patients Loss of autonomy due to

The Sport Physical: Insanity and Magic

A father stands anxiously at the window to our reception desk, shifting his weight from side to side, clutching at a piece of paper.  “ My son can’t play football unless this form is signed, and practice starts this afternoon.  Can’t you help me?”   “Unfortunately,” explains my receptionist, “We are booking out 6 to 8 weeks for a well check up.  Our same day appointments are set aside for patients with serious, acute illnesses, and besides, sport physicals are not covered by insurances.”   “What am I supposed to do?”  asks the distraught parent.  The receptionist gives him a sympathetic look and hurries to answer the persistently ringing phone.  Some desperate families actually go to the emergency room to get their sport physical forms filled out.  Thus the insanity of the sport physical season plays out. Typically, the required paperwork is handed out to families in late July, and the school system expects physician offices to to see all student athletes in a two week time period during…

Shape Up or Ship Out!

We are coming to the end of the first year of the Affordable Care Act (ACA).  Although the ACA ushered in an era of improvements, we still have a long way to go.   Devin Miller, Washington correspondent for the American Academy of Pediatrics, optimistically reports that more children that ever are currently insured, thanks to the ACA, Medicaid, and the Children’s Health Insurance Program. 1 He reports a 25% reduction in the number of uninsured Americans, which should be great news.    My question is, what does “being insured” mean?  In my experience, the new Covered California plans generally have a large deductibles, sizable co-pays, restrictive formularies accompanied by many exclusions.  If you can still go bankrupt from medical bills while insured, how much good has this done?   We are happy that many more people have insurance now, but that needs to translate into good medical care for policy-holders.  If the insurance industry does not step up and become a good partner in the he…