Fee For Service

Not too many years ago, as the many-layered onion that is physiciandom brought tears more and more constantly to my eyes, I said, "What the hell, I give up. If this is all just a way to break us down and put us on salary, bring it on. Just tell me how much I'll get, and I'll decide if I want to keep doing it."

Paperwork propagating like potatoes; rules compounding themselves like viruses; payments receding like ice-caps. There's no doubt it affected my enjoyment of my work, steadily plunging the pleasure, the honor, the gift, and the psychic rewards of being a surgeon deeper into the bulb of the allium, harder to find without crying. And yet such thoughts find little if any resonance with the public. Fee for service, it's said, is the root of the economic evils of our health care system. I don't entirely disagree: what we have now is the worst of all possibilities.

There are many ways in which health care doesn't follow other capitalistic models. Attempts at controlling costs have included, for instance, both restricting and increasing the number of doctors produced in medical schools. Neither worked. To date, disguised and dressed in many pretty outfits, the main tool for cutting costs has been reducing payments to physicians and to hospitals. At best, results are mixed: forced to work harder and harder to maintain income, many doctors (speaking) have burned out and quit in their prime. Turned into bean-counters, those that stay have adopted methods that frustrate patients: cramming more visits into an hour, charging for phone calls, etc... Ancillary charges are outrageous: a friend recently wrote me about a $3,500 CAT scan, a charge of $850 for a simple automated blood test. (Not that anyone but the uninsured actually pays them: in some sort of dance macabre, insurers reimburse ten or twenty percent of those fees and the rest is smoke.)

(In a related note, I read that President Obama's doctor isn't happy with Obama's health reform proposals. In the article the good doctor says neurosurgeons get $20,000 for "cutting into the neck" of his patients. Now, I have no idea what goes on in Chicago, but I'd propose that, if twenty grand is an actual fee, like the $3,500 CAT scan, the reimbursement is a small fraction. In this post I don't want to get, yet again, into the frictions between surgeons and real doctors; but such a claim suggests a certain amount of hyperbole in the discussion. On the other hand, he implies he's for a single-payer plan; on that, we agree!)

Pay for doing stuff is the wrong incentive, so we are told. It leads to over-ordering of tests, over-doing of procedures. Can't entirely disagree. Read Atul Gawande in The New Yorker, or Buckeye Surgeon in Buckeye Surgeon. But if it's a problem, what is the solution? Salaries, says Atul. Better docs, says Buck. And me. With the right incentives.

I've said before -- to hoots and snark -- that I don't think many physicians are in it primarily for the money. But I do believe that, as in most other professional pursuits, people willing to work hard and who produce superior results have an expectation of some sort of recognition. Which includes income. And that's precisely why I said above that what we have now is the worst of all possibilities; fee for service with no incentives for quality, no differentiation among bad, mediocre, and excellent providers. For doing a colon resection in half the operative time (saving thousands in OR costs), sending a happy patient home two or three days (or more) sooner than average (saving thousands in hospital costs), with a lower rate of complications, I got exactly the same reimbursement -- from Medicare, from any insurance company -- as the surgeon who did none of those things. If, to a payor, a colon resection is a widget, the only criterion for payment for which is agreement to accept the latest slice in compensation, why bother to do those things? (Getting patients home quickly requires, among other things, making rounds two or three times a day, which most docs no longer do -- but which I always did. Faster operative times result from many things, among which are attention to detail, making sure in advance that what you need is in the room, keeping the team informed of what's coming next. Even helping move the patient and clean the room. Not seen frequently. Since I retired.)

A high percentage of doctors are human beings. That means they often respond like other people. Incentives and disincentives have an effect on behavior. Which is among the reasons "effectiveness research," or whatever the proper name for the effort (the blocking of which is desired by several legislators on the rive droit) to identify best treatments, makes nothing but sense.

I suppose it gets tiresome to read such treati. The bottom line is I think a system works best when there are incentives -- positive and negative -- to do the right thing. Some will, no matter what. (Of those, some have hung it up...) Salaries (at least those with no opportunity for adjustment based on performance) encourage laziness; capitation encourages the withholding of care. Fee for service which makes no allowance for differences in quality encourages abuse. And burnout.

Based on the snippets coming from the halls of Congress, I'm pretty well convinced that whatever so-called reform we get will fail substantively to address the real problems in our system: insurers, excessive or inappropriate "care," reasonable reimbursement across all fields of medicine, costs. And, for the life of me, I can't understand why.

Well, of course, I can.

The Death of Health Care

In today's New York Times there's an article that addresses something I've argued for a long time: the way to control costs of health care is to look at how and why costs and practices differ, and to adopt the best practices.

Now this article in particular is about the costs of end-of-life care, which is tricky. Even better, though, as a point of discussion, because it's been shown that a huge amount of the health care dollar is spent in the last months of life. Were this area looked at -- really looked at -- we'd have a paradigm in which to figure out what we really want from our health care money. About 30% of Medicare money is spent in the last year of life. Of that, 40% is spent in the last month. It's not surprising, of course: you tend to be sick before you die. So one would hope. Still, it would seem that in the variations described in the NYT article, there's much to be learned. Is it the same care being delivered more efficiently? Is it philosophical?

I don't know the answer, and I've already posted once today, so I'll wax waningly. I'm just saying that it's about time to turn our attention to where the real money is and have a little candid politicking. Candidates propose ways to fund insurance. Scheduled to go into effect this year and next are major cuts in physician payments by Medicare. Politically popular. Easy. And looking exactly 180 degrees away from the heart of the matter.

F*ck 'Em

Or help 'em. Those, it seems, are the philosophical options in the funding of health care nowadays. In order to balance the budget, George Bush wants major cuts in Medicare and Medicaid. Primarily, his plan is to cut back on payments to hospitals and nursing homes. There is also on the table a pending cut of ten percent in reimbursements to physicians, but I'll not make this post about that except to say the obvious: there's only so much blood in that turnip. Somewhere there's a floor below which doctors can't and won't go. We're there, in my opinion. Care will become less available. But I'm out of the provider loop nowadays. So let's talk about recipients.

What do you do with people who can't, for whatever reason, afford medical care? You either bar the door, or you let them in. F*ck 'em, in other words, or help 'em. And if you help them, but don't pay hospitals enough to cover the costs, then in order to stay afloat, hospitals must shift the burden to those who do have coverage. Our politicians may be cool with deficit spending, but hospitals aren't, and can't be.

Controlling Medicare and Medicaid costs mainly by cutting reimbursement is, to use a sophisticated economic term, moronic. Unless the plan is to ration care by putting a bunch of hospitals out of business. I'm all for accountability and for the eliminating of waste in the system and for promoting best practices. But, as I've said previously, at some point this country will have to face the fundamental question: how much can we spend on health care, and how will we divvy it up? If we choose to ration care, or to have different levels of care for those that can pay and for those that can't, then let's just stand up and say it, rather than slither around it.

The problem with the (conservative) view that people ought to bear responsibility for their health care and retirement costs is that not everyone can. Many people count on Social Security -- anathema to so many on the right -- and retirees are expected by their former places of work to have Medicare to cover their medical needs at some point. It makes sense to me to index premiums and payouts based on a person's ability to pay. But the scattershot approach of continually lowering reimbursement to providers is chickenshit: it begs the question, and hides the real philosophical differences at work. Picking up corpses is cheaper than paying for care (if they smell bad, we could have illegal aliens do it). So would it be to send those who can't afford care to some place where they can do their damn duty and die. But if that's abhorrent, and if we choose to provide care, then cutting the payments for it simply shifts costs to businesses and rich people -- the very constituency Bush is trying to protect in choosing to pay less rather than to increase revenue. Isn't it cleaner and more transparent to adjust taxes to cover expenses (while doing everything possible to reduce costs)? Maybe the upcoming election will clarify where, as a country, we stand. F*ck 'em, or help 'em. Time to make the call.

Oh, and George's budget also has significant cuts in funding for medical research, as well as a 400 billion dollar deficit. So fuck us all.

One More Time

When I was "interviewed" for a website recently, one of the questions was if another blogger and I had stopped feuding. Not that I know of, was what I said. I'm not sure if there's been a feud, for one thing. For another, I feel teensy bad that many moons ago I did make some (possibly inappropriately) snide comments about his chosen field. The reason I bring it up now is that there've been a lot of articles lately that suggest that lots of people have no idea what it really means to be a doctor. Crazy stuff, some of it.

In the formative days of this blog, I wrote once about shortcomings I saw in family practice docs coming right out of training. (I find many of my older posts embarrassingly bad, so I'm not even going to look for and quote myself.) What I hope I said was along these lines: worse than a doctor who doesn't know stuff is a doctor who doesn't know s/he doesn't know stuff. Compared to specialty training -- in which it seems half the time is spent reminding (putting it nicely) trainees how little they know -- it was my impression that (at least at one time) the opposite seemed true of family practice. I probably didn't acknowledge that it's nearly an impossible task: teaching people a smattering of everything -- enough to know both what they're doing and to recognize when they don't. Still, the FPs I worked with who were freshly minted knew much less than they thought they did about the topics with which we dealt in common: breast lumps, breast cancer. Gallbladder problems, hernias, hemorrhoids. Colon things. Various stuff. (I put on some seminars, which helped.) And yet they happily (because, I assume, they weren't taught any differently) took on issues with no sense of discomfort or of a need for input. It may be intangible: but a doctor simply MUST know his/her limits. The shorter the training, the less intense (maybe, even, the kinder and gentler), the more poorly is that goal met. Now, in all specialties, that appears to be exactly where we're headed.

I think I also said -- and if I didn't, I should have -- that the FPs I knew who'd been around awhile were excellent docs. It just seemed to take a while to assimilate the sense of limits (not to mention to broaden the limits outward); and I think that's not as true of most specialty-trained docs. Acknowledging once more that many doctors share much in common with human beings, it's true that within any subset there are exceptions to the left, and to the right.

So why am I picking this scab again? Because of my recent post in response to an article in the NYT decrying doctors' incomes, and the comments thereon, as well as several related posts and comments in the recent medical blogosphere. Still more: I got an email from an excellent young medblogger asking my opinion about a post by some sort of health/fitness blogger in which he claimed that it should take way less time to train doctors; that you ought to be able to learn surgery in a couple of years. Procedures, he said, are often taught nowadays by reps from instrument companies, so how hard can it be?

Related is the concept bandied about by commenters here and elsewhere that all our health care money problems will be solved simply by cutting what doctors are paid and by cranking out way more docs. Perhaps the best of all was the prediction that any gaps in physician availability would be happily made up by women who want to be part-time docs and moms.

Still another connected issue is the on-going discussion among other bloggers regarding the 80-hour work week, and how us old farts who trained in the days of much longer hours simply haven't a clue about how clueless we are. These generally include tirades at how particularly egregious is surgical training and the arrogance of those within -- more the teachers than the teachees. But them, too.

And finally, my blog and those of others are rife with comments by people who've been treated egregiously by doctors. Truly. Egregiously. I'm embarrassed just to read some of the stuff; particularly as it reveals complete lack of communication skills, compassion, and empathy on the part of those doctors.

OK. I probably have neither the will nor the skill to do justice to bringing together all of these themes. Except to say this: there seems to be a very schizophrenic attitude about physicians. People want more knowledgeable doctors, ones that will listen better and explain more clearly. Docs that will fully enumerate and carefully explain all the issues and choices for any situation; who will be sensitive to their individual needs, who will both guide them but let them make all their own decisions. And, of course, doctors with comprehensively flawless knowledge and impeccably perfect skills. People criticize doctors -- surgeons especially -- for having a god-complex, but they want god-like perfection. To achieve it, they suggest flooding the market with doctors and spending less time training them. And, of course, after people flock to become these perfect doctors, to pay them less and less for their efforts. Highly qualified, well-motivated folks with altruism aplenty will fight their way to the front of the line.

Especially moms.

Talked to the tooth fairy lately?