A Penny (Or More) For Your Thoughts

By Kim Bellard, September 13, 2011

Let’s start with the non-news: a primary care physician association – in this case, the American Academy of Family Physicians – thinks primary care physicians aren’t being paid enough fairly and wants CMS to change the Medicare payment system.   It would be a surprise if any primary care physician organization argued any other position, and there is a lot of sympathy for the argument that primary care physicians are undervalued compared to specialists.   I’m sympathetic myself.

On the other hand, a new study in Health Affairs asserts that primary care physicians in the U.S. both are paid higher fees than primary care physicians in several other countries and also have higher incomes as a result.  The study, by Laugesen and Glied, further asserts that the higher incomes are simply the function of the higher fees, not due to higher practice costs, higher volumes, or medical school tuitions, as some have theorized.  The study also notes that the same type of gap exists for orthopedists in the U.S. versus in other countries, and that the income gap between U.S. primary care physicians and orthopedists is wider than in other countries. 

The fact of higher physician fees and physician incomes for U.S. physicians compared to their international peers is nothing new, and I’ve blogged about this previously.   With the ongoing and increasing pressures on Medicare and Medicaid spending, we can expect even more pressure on how we pay which physicians.  No one seems to be stepping up to say that they are overpaid.

A few other recent studies give me pause about this topic.  On of the most interesting was a study from Israel that concluded medical history and examination were more important than extra tests, particularly CT scans, in making a diagnosis.  The authors found that added tests only helped in about one-third of the cases, while adding significant costs and exposing patients to additional radiation and its attendant risks (see, for example, this nice summary).  This was in Israel, mind you, and one can only imagine how many more “extra” tests are performed in the U.S., given our culture to always do more and patients’ demand that everything possible be done, regardless of cost-benefit.  It’s nice to have it confirmed empirically that cognitive skills still trump technology most of the time. 

An example that dramatically illustrates this is a recent study about the effectiveness of “brain stents” to prevent strokes.  The study not only found the costly procedure was not more effective, but actually was worse for patients than those treated conservatively with drugs and advice.  Patients with the stents had more strokes and more deaths, to the extent that the study was halted prematurely once the results became clear.  Interestingly, this study is on the heels of another recent study indicating that heart stents were not more effective than medication, yet the number of such stents being performed hadn’t gone down once those results had become widely known.  The U.S. health system just seems to be in love with procedures and testing, not always to be benefit of its patients.

Now, some observers might view the results from Israel and claim that, well, if it was your mother/spouse/child, surely you would want those extra tests as well, just to make sure, since in one of three times they did prove to be useful.  It isn’t easy, after all, to tell which of the three will benefit before the fact.  It’s a valid argument, and this attitude is typical of our health care system, where doing more is usually seen as better.  We don’t seem to have this attitude in all aspects of our life.  If, say, it turned out that police routinely arrested three people to find the one person who was guilty, there would be cries of outrage across the board.  We’d argue indignantly that the police need to take a little more time to be sure they had the right person before making arrests.  We seem to hold our policemen to higher standards than we do our health care practitioners, and I’m not quite sure why.

I enjoy watching the television show House, in which it’s grumpy, damaged lead physician plays Sherlock Holmes with baffling diseases, eventually putting together all the clues to (usually) save the patients’ lives.  Every time I watch it, though, I have two reactions – first, those poor patients, who are put through a bewildering and often painful array of tests and procedures before the Dr. House reaches his miraculous conclusion, and, second, who is paying for all this?  There’s never any real sense that Dr. House and his team ever worry about how much their efforts are costing, and there seems scant concern for what they put the patients through.  All House cares about is getting to the right diagnosis.  It’s great TV but a horrible patient experience.

So here’s my thought.  Let’s pay physicians more for the cognitive work, the so-called Evaluation and Management codes (“E&M”).  All doctors, any doctors, plus nurse practitioners and other physician extenders.  It’s less important which doctors get it than what we incent them to do, and what we should want them to do first and foremost is to use their intellect, training and experience to figure out what is or might be wrong with us.  “First do no harm” and all that.

We should give them not just a token increase but a major one – double, triple, pick a number, but make it a very noticeable one.  I would assert that the health care system won’t go bankrupt – well, more bankrupt – because of too many office visits, even if we start paying for e-visits and telemedicine visits, as we should.  It’s what happens from those office visits that we have to worry about – the prescriptions, the tests, the procedures and treatments that result.  Of course, we’d need to find a way to ensure that those added payments for E&M visits aren’t just additive, but actually help deter other inventions that are not truly necessary.

The pot of money available in health care is, for practical purposes, a zero-sum game.  Pretty soon employees are going to realize that their “employer contributions” for health care is their own money, and pretty soon the federal government is going to have a harder time paying for its health programs using deficit financing.  So whatever we increase in E&M payments will need to come from elsewhere in the existing spending.  For example, could we use “thinking time” as the unit of measure, so that a procedure which takes an hour to perform should get paid the same as seeing patients for an hour?  Alternatively, perhaps many tests and procedures should end up getting paid more like a commodity – more expensive initially as people learn how to do them and as the initial development costs get paid for, then rapidly dropping the price as volume increases and people get used to doing them.  We have a tendency to start out high and never drop payment levels.   Smarter people than me can figure out exactly how to make the offset, although the lobbying opposition will be very intense as every specialty fights to protect its turf.

We all like to think that the patient-physician relationship is sacrosanct.  So why not pay for it like we actually believed that?

Comments

[Mary Kohne]

I want to send this to our Dr. who is JohnJ, Nolan but don't know his address.