Tuesday, July 31, 2007

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.


rlbates said...

It is certainly a can o'worms. I, like you, try not to let what I will get paid be a deciding factor as to which procedure (if any) a will do for a patient. I have talked many women out of breast augmentations (even when I needed the income to pay my overhead). Sometimes I would love the security of a "salary", let others worry about the rent, utilities, but I worry then that "they" would tell me I "had" to do the operation as "they" would want the payment.

Sure wish I had the answer. I work for the patient. My reward is a good outcome. But I have learned you can't be here to give service, if the overhead is not met.

Dr. Rob said...

I agree with your assessment (see my last post on free market). The whole thing is a big mess and I think that one of the biggest things is to get the other fingers out of the pie. Too many people are leaching money out of the system for no other reason than the fact that they can. I do believe in rewarding quality and rewarding hard work (Salaried physicians do not work as hard as those motivated by profits). The problem is defining quality and really rewarding the work and not how well you play the game.

If you can fix the problem, I will campaign for your election as Emperor of the Universe.

Sid Schwab said...

rlbates: yeah. After the latest list of rules, the most recent hassle with this carrier or that, I've often said, just give me a salary: tell what it'll be, and if I can live with it, I will, and if not, I'll find something else to do.

rob: I was hoping you'd be the one.

Anonymous said...

Even if all those things come to pass, I'm willing to bet we'll also see an influx of capable, smart, committed young physicians who are utterly content to accept a salary, rather than unlimited wealth, in exchange for a controllable schedule and a 50-hour workweek. The ones who drop out because they can no longer overtime their way to a Porsche Carrera GT will be replaced (sooner or later) by 40-year-old women who seize the opportunity to both save lives AND see more of their kids. That's the "different sort of person" you'll see more of. Wait times may peak in the short term, but they'll flatten out again as the supply adjusts.

Anonymous said...

The short term? You mean the 12+ years it will take between any attempt at increasing the supply of physicians to account for decreases in the work done by the current ones?

Well, I certainly hope you don't break your arm in that "short" 12 years then.

There is an enormous amount of "free labor" by physicians put into the current system out of good will and professional obligation. If the government wants to crack it in an attempt to pinch pennies, it will be surprised when it turns out to cost many more pounds. The British NHS offered doctors a pay cut in exchange for giving up night call because they didn't believe those lying doctors about how much they worked for free. Turns out it was actually a massive underestimation and the doctors are enjoying their free nights as the NHS must now pay billions more because it's not being done for free anymore. Careful what you wish for...

Anonymous said...

Great post.

Re: salary; some years ago I worked in a hospital-owned clinic. We three FPs were on salary. One would always, always leave on time (or early!), leaving whatever still needed to be done to the other two, knowing we would because we didn't want to leave the patients in the lurch. I left as soon as my contract was up or I might have gotten bitter. I suspect we were a perfect microcosm of what it would be like to have all docs on salary.

Re: Medicare payments to doctors going up, TOTAL payments are going up because of spiraling demand. Reimbursement for any given service is not going up much or in some cases not at all. So docs are making less for a given amount of work.

Pick your poison--should docs get paid for doing work--I include "cognitive" work ;) or for *not* doing work, as when capitated or salaried. If I were the patient, I'd pick the former.

Unknown said...

Just out of curiosity - What was a big concern when you were just starting out in medicine? My generation is of course concerned about paying back loans when our paychecks get slashed in the name of HMO.

Sid Schwab said...

anne: good question. I think for people my age, there weren't a lot of worries; maybe that's why so many are now unhappy. We came in on the tail end of the times when the main worries were what you wanted to do, and where. Finding a good location wasn't a sure thing, but it wasn't a problem for anyone who'd done well. I think that part is still true; but I don't think many of us worried that we'd make a decent living. Frankly, I never really thought about money at that stage. I saved $4000 of my $8000 salary as an intern. It was more than I'd ever made. I went into the military after internship and with combat pay and flight pay I thought I was rolling in dough. I made $12K as a chief, and my guarantee when I started practice was $30K. At every stage, it was more than I'd ever made. When I started in practice, my partners asked how much surgery I thought I'd want to do to feel useful. Ten cases a week? You'll kill yourself, they said. Six cases is nice: you can make a decent living and have time for a life. By the latter part of my career, I was doing up to twenty a week, and making about what those guys were making, in comparative dollars. So I went from the time of little regulation, fee for service, to that of lots of rules, many carriers calling lots of shots, and steady decline in reimbursement. I can't say the old days were fair: I think, for example, you ought to be doing more than six cases a week. But right or wrong, a lot has changed. I think it's not just money for your generation; it's uncertainty of what it will look like 10 or 20 years from now. Me? I'm hoping not to get sick.

james gaulte said...

"Bonuses based on health on patients"
Talk about hubris.Do we really think that the health of patients in under our control.Sometimes we help peple because we know what we are doing and we do the right thing and the patient cooperates. Sometimes the patient has great genes in regard to the issue at hand and they do well anyway. People live and die and much of time survival is unrelated or barely realted to what we do.So we should be paid more if our patients have good biological systems that keep them going longer.

Jeffrey Parks MD FACS said...

Bonuses based on outcomes can get a little tricky for surgeons especially. Tertiary referral centers often end up with patients that the community hospitals want no part of. The man with a pancreatic cancer invading his SMV. The woman acutely short of breath who needs a re-do CABG emergently for the third time. The case of severe pancreatitis and multiple organ failure who needs pancreatic debridement. outcomes aren't going to be so hot, no matter who does the surgery. It's simply a reflection of patient selection.

Unknown said...

Dr. Schwab, that's really interesting. I hope my future paycheck isn't too small, because my loans are getting rather intimidating. I keep waiting for that rich uncle to come to my rescue, but so far, no luck. Know any benevolent donors?

Anonymous said...

SO, no question, financial incentives and disincentives have an effect;that's why a market based system works. As to the assertion that physician supply will rise to meet demand regardless of payment, that flys in the face of market theory, and is belied in the UK; just review the "Say goodbye to doctor" post (july 25) in UK blog doctor. Heck, we already have a payment based supply shortage in primary care in the Southwest. Once reimbursement gets low enough, the market will find its own level; if prices are regulated by the government without recourse, there will arise a "black market" in healthcare, just like there are black markets everywhere there are government price controls. Black market is one way to characterize the rise of "concierge medicine" by the way. It just isn't illegal (yet).

RATIONING, of course, is the underlying motivation; everybody can't have everything they think they need-there's just not enough to go around and still have a productive economy, no matter how efficient you become. the UK and Canada ration by wait, we ration by HMO denial and ability to pay (think healthcare is available in the ER like the president claims? If you are indigent, just try to get that breast mass removed before the mets get you, or that tooth extracted before you are septic.) If we are going to ration (and it seems inevitable) we ought to have honest public acknowledgment of who gets and who doesn't and why; playing pretend like we are doing is safe politics but bad policy. Any health care economist who is being candid and off the record will tell you this is so.

Bongi said...

supply and demand. but the time and effort put into becoming a doctor, reflected often in the astronomical student loans may make it not worth anyone's while. i like moe's philanthropic sentiments but i don't think there are enough people willing to put themselves through so much just to have the right to save lives. besides these women he talks about seeing their children, what happens when some selfish patient attempts to die after hours?

especially surgeons. in our country we have a growing shortage of them. who wants to study for 15 years to end up doing this type of work for dropping wages and massive student loans. sorry, especially in surgery these women will not suddenly appear to fill the void. i agree with sid. my basic plan is to not get sick when i'm older.

Lynn Price said...

I'm willing to bet we'll see an influx of capable, smart, committed young physicians who are utterly content to accept a salary, rather than unlimited wealth, in exchange for a controllable schedule and a 50-hour workweek.

I doubt it. From what I hear, residency smacks all Utopian thought right out of one's head. People used to say this about teachers, too, and you don't have to look far to see their contract negotiations are a continuing source of angst.

The ones who drop out because they can no longer overtime their way to a Porsche Carrera GT will be replaced (sooner or later) by 40-year-old women who seize the opportunity to both save lives AND see more of their kids.

You seem to mistake a person willing to work for less as being the best choice. Not in my world. I'm all for a sale, but not when it comes to medical care. Benevolence only goes so far and it will never usurp Man's natural desire to exceed and be properly compensated. The only way to get the best is to pay for it. It's in our genetics.

Dr. Rob Oliver Jr. said...


Did you catch the letter from economist Uwe Reinhardt in the Sunday NYT yesterday about the article you refer to?

I mention this (and you) today over on Plastic Surgery 101.



Happyman said...

Bonuses based on patients' health? The bean-counters look up simple guidelines & try to extrapolate quality of physician care based on claims-data ALREADY.

I wrote rxs for my father-in-law once for his glucophage, since he moved & didn't hook up with a new MD (mistake, I admit). Thereafter I got regular contacts from "Active Health Management" asking me to copy & fax sections of the chart where I documented eye exams, HbA1c values, urine microalbumin, nutritional counselling, etc.

So let's say it WASN'T my father-in-law, but rather was my patient, and he/she simply didn't follow my instructions, fill meds, get labs, follow-up, etc.? Do I get dinged for that? That is the essence of P4P.

And by the way, all of that extra paperwork is totally unreimbursed.

The message is clear - simply don't take on complicated patients (e.g. diabetes, cancer, heart disease, geriatric, etc).
I echo the prior sentiments, & just hope I don't get sick; otherwise thankfully I went to med school & residency for umpteen years. So much for everyone else.


Moving this post to the head of the list, I present a recently expanded sampling of what this blog has been about. Occasional rant aside, i...