This week was not a good one in our area for getting an appointment with an endocrinologist. Most of our endo’s are over 60 years old and we have only had two new endocrinologists come into the area in the past four years. What makes it harder is that two endo’s have cut down to four half-days each week and one of the busiest just announced his retirement. Part of the reason we are not seeing new clinicians in our area must have something to do with the way we are administering healthcare and paying these specialists.
As most of you know diabetes patients are the most time-consuming patients we see and with the advent of ACO’s, capitation, pay for performance and patient quotas, many times there is just not enough time to see a diabetes patient. Often I see a patient and will discover after 30 minutes that the patient has quit taking a medication or is taking it wrong. If I did not have the time as an educator, I would have never known.
According to Alan J. Garber, MD, PhD, this is because the traditional small practices that endocrinologists used to have, where they could spend time with patients, were invaded by HMO’s and reimbursement decrease while patient loads increased. He also points out that many hospitals don’t have an endocrinologist on staff anymore. He went on to say that those endo’s who work at university hospitals are often so micro-managed for time that they cannot give adequate time to patients.
His idea of the future is the resurgence of small group practices as boutiques that offer services outside of the large, governmental reimbursement schemes. They will be similar to those which have grown up in the United Kingdom, in which about 15% of patients all have outside private insurance and seek their care at such sites rather than in the National Health Service. The same two-tier system will likely develop here because many individuals want the best health care and are willing to pay for it. This return to the smaller offices of old will lower overhead and enable cost-effective endocrine practice outside governmental systems. If you don’t believe he has a good handle on the future be sure you check out this week’s item on Diabetes Optimal Care Not Cost Effective that just backs up what Dr. Garber had to say.
Dave Joffe, Editor-in-chief