Times Two

Sunday's New York Times had a couple of features of medical/surgical interest. The first was a very long article on the variations in cancer treatments at various centers in the US, focusing on a young woman with colon cancer. She was diagnosed at Stage IV, meaning it had spread to her liver; in her case, very extensively. It was evidently only by her own perseverance that she finally ended up with intense chemotherapy and radical liver surgery which, statistically speaking, has a low probability of long-term benefit but which, for now, has left her overtly disease-free. Orac posted extensively on the subject, making anything I'd say mostly overage. But it is a very significant issue, even if the article -- as one would expect regarding a very complex topic -- has certain shortcomings. That there are variations in approaches to many illnesses -- in this case cancer -- and in the skills and philosophies of the doctors rendering the care is a problem for which there will never be a perfect solution. But it speaks for the creation of (and agreement upon!) well thought-out protocols covering a wide range of possible expressions of the disease, and is an argument in favor of something about which I have mixed feelings. Namely, "centers-of-excellence." Suffice it, for now, to say that I agree that for certain complex problems a team approach is ideal, and finding ways in which to evaluate the outcomes of such teams is laudable; but what I've seen of it leaves a certain amount to be desired. For example, I know of a place designated a center of excellence not far from where I am, in a field with which I have professional familiarity, that seems anything but. If the idea is a good one, the execution is what it's all about. Nor did the article address the even more difficult question of cost-benefit. Tough stuff, all of it.


The other commentary decried the fee-for-service model of physician reimbursement, in the context of running up costs because doctors get paid to do things. In part, the article, by Alex Berenson, says:

"Americans generally do not seem to mind the fact that doctors are well paid. In public opinion surveys, doctors usually rank as the most trusted professionals. Congress has repeatedly blocked Medicare’s efforts to reduce the amount it pays for each procedure doctors perform, even though overall Medicare payments to doctors are soaring and the cuts are legally required to keep the program’s budget balanced. [Ahem. Sorry to interrupt, Alex: whereas it's true that in the past couple of years, some fees have been allowed to rise a couple of percentage points (hardly "soar"), that's only after having cut reimbursement by around two-thirds, steadily, over several previous years.] The way that doctors are paid may be an even more significant factor driving up costs and may lead to unnecessary care, said Dr. Peter B. Bach, a pulmonary physician at Memorial Sloan-Kettering Cancer Center and a former senior adviser to Medicare and Medicaid. In the United States, nearly all doctors are paid piecemeal, for each test or procedure they perform, rather than a flat salary. As a result, physicians have financial incentives to perform procedures that further drive up overall health care spending. Doctors are paid little for routine examinations and very little for “cognitive services,” such as researching different treatment options or offering advice to help patients get better without treatment. “I don’t have a view on whether doctors take home too much money or not enough money,” Dr. Bach said. “The problem is the way they earn their money. They have to do stuff. They have to do procedures.”

Primary care doctors and pediatricians, who rarely perform complex procedures, make less than specialists. They are attracting a declining percentage of medical students, and some states are facing a shortage of primary care doctors. Doctors are also paid whether the procedures they perform go well or badly, Dr. Bach said, and whether they are crucial to a patient’s health or not... “Almost all expenditures pass through the pen of a doctor,” he said. So a doctor may decide to perform a test that costs a total of $4,000 in order to make $800 for himself — when a cheaper test might work equally well. “This is a highly inefficient way to pay doctors,” Dr. Bach said....

....Private insurers like H.M.O.’s are more aggressive than Medicare in second-guessing physicians’ clinical decisions, and they will refuse to pay for imaging scans or other expensive new procedures. Now Medicare and private insurers are moving cautiously to change the current system. Recently, they have proposed pay-for-performance measures that would give doctors small bonuses if their care meets the standards set by national medical organizations such as the American Heart Association. But all those measures are a minor fix, said Dr. Alan Garber, a practicing internist and the director of the Center for Health Policy at Stanford University. Instead, he argues, the United States should move toward paying doctors fixed salaries, plus bonuses based on the health of the patients they care for..."

I get it. It's easy to think -- and it's not entirely false -- that some doctors make treatment decisions based in part on how much money they'll make. (Being as honest with myself as I can, I don't believe I ever did. I know I rejected operating on lots of folks who were all teed up for it by their referring docs. But if someone pulled all the data out my brain -- what's left of it -- and ran some sort of algorithm or other, maybe it could show some cases...) And it's probably true that if doctors were all on salary, overall health costs would go down. But the questions are 1) why, and 2) what would it look like?

I've mentioned before, and I should reiterate here: many doctors -- including, amazingly enough, some surgeons -- are (or sometimes act like) human beings. Incentives and rewards are as likely to be important to them as to actual people. Working hard for its own sake, striving for excellence without any tangible recognition will be seen in some -- but hardly most-- doctors if they go on a salary. Because, unsurprisingly (or maybe surprisingly, to pundits) that's not how it works in real life. I've been in the military, and I've worked at VA hospitals. Try getting a case on after three p.m. Try getting a lab test or Xray thenabouts. Work another patient into a crowded schedule? Stay through lunch, after hours, come in early? Sorry. That's what ERs are for. If Alex is ok with it, so am I. Sleep, I've discovered, can be a pleasant thing.

In "my solution (here and here)" I suggested the opposite of salary: in fact, I argued that paying every doctor the same for a given item of work was counter-productive; that finding ways to incentivize and reward higher quality would lead to lower costs and better results. The NYT article suggests salary plus "bonuses based on the health" of their patients. Can you say "can o' worms?" Might some doctor-humans prune their practices of difficult patients? Could those willing to take on the very sick be penalized? And, to tie the two Times articles together, in a a world of salaried physicians, my crystal ball says the lady in the first piece would have an even harder time getting the care she got.

Breaking ranks with the majority of my peers, I've said a single-payor system makes sense to me. But salary doesn't. It will indeed lower costs, because people simply won't bust their asses any more. I did significantly more than twice the average number of operations per year than the typical general surgeon (and because I was in a large (enormous) clinic with very high overhead for specialists, I made less than the average surgeon in the country, by a depressing amount); I did it because people needed the care. But I'm pretty damn sure I'd have cut my hours back to what everyone else was putting in if I'd been on a salary. If we go there, wait times will go way up. There'll be waiting lists. In training, at the VA, there were people waiting for every sort of operation: as Chief Resident I could have simply made up schedules based on what I wanted to do, maybe never getting around to some. And let's be real: as I've also said before, if you take away reward for hard work and excellent product, you'll find a very different sort of person -- on average -- choosing to become physicians. If that's not seen as a problem, so be it.

To use the Rumsfeldian/Socratic method here: Is the system broken? Yes. Does it need major overhaul? Sure as hell. Is the solution to put doctors on salary? NFW. Not unless we are, as a nation, willing to accept longer waits for more mediocre care. That old human thing, once again.