Physicians: Health Cost Elephants in the Room?

Call it what you will - gaming, flat of the curve medicine, perverse fee-for-service incentives, doing more to make more, inappropriate testing or treatment to maximize income, defensive medicine, self-referral, or, on the flip side, enlightened self-interest.

Whatever you call it, a bevy of critics are saying the elephant in the room causing excessive health costs are “ungoverned” doctors in small practices, large practices, and academic medical centers are ordering tests, doing operations, mindlessly over-using technology, referring to themselves, buying unneeded technologies, cutting deals -- all to maximize income rather than practicing “quality” medicine to make patients better or to enhance outcomes. These critics tend to inhabit office suites of payers far removed from action on the ground and from what drives doctors and their patients.

I run across these critics often when I write of health reform. Their comments, generally nonspecific or sotto voce so as not to be overhead, run along these lines,” We’r to blame for these high costs.” “We’re the villains.” “What else can you do in a system like this when Medicare and health plans keep ratcheting down your reimbursements.?” Or, “It’s just plain greed.”

Now I am not one to sit in judgment of my fellow physicians. We all do things for a reason, and all of us take steps to stabilize our revenues. There are a lot of factors at work here, including high education debts and escalating, escalating overhead, and whole new set of suggested (expesnive) solutions – protocols, evidence-based medicine, P4P, and, of course, that ceaseless pressure to install EMRs at your own expense in the name of quality.

And the solutions are myriad as well;

• Place doctors on salary to remove financial incentives.
• Slash pay gaps between specialists and primary care doctors and produce more of the latter, who cost less.
• Make all pricing and costs transparent and public.
• Bundle hospital and doctor bills so consumers can know in advance what to expect.
• Place computers at doctors’ fingertips so they can compare, share, and judge what works.
• Use “systems engineering” to redesign the whole system to ensure the best care at the best time for the right reason.
• Encourage doctors to join large groups with enough data infrastructure so outside payers and inside physicians can oversee each other.

There are, of course, two main schools of thought:

• One, let government take care of everything – pricing, regulations, monitoring of quality, and auditing, punishment, and rewards for physicians who play the government game.
• Two, wait for the storm of changes now moving through the marketplace - retail clinics (now numbering about 1000), worksite clinics (perhaps 500), and high deductible health plans (15% of employees now belong), and outrage over high costs to induce competition and bring costs down.

I happen to think “the system” and “American culture” dictates how physicians and patients behave. Each rests on believes in individualism, choice, and freedom to chose what technology and treatment options to pursue. In short, free enterprise.

\It may be that pay-for-performance programs, initiated and monitored by government, as in England, where 25% of physician income, is tied to quality, is a partial answer, but that approach is easier said than done, and doctors may exclude patients from P4P targets to increase income, a practice know as “gaming.”

In the long run, savvy informed patients spending their own premium monies, may the best safeguard against excess care.