Saturday, June 4, 2011

Why Cognitive Doctors Need To Be Paid More

Preface: On June 3,, America's most widely read physician blog, reran this blog of mine.

Everybody has a theory of what’s wrong with American health care and why costs are high.

I have my own theory – talk is cheap. By this, I mean Americans and third party payers are unwilling to pay more for what mere talk is worth.

They do not want to pay more for a visit to the family doctor, other primary care physicians, or a psychiatrist. They pay primary care doctors only 55% of what average specialist makes, and only 30% of what an orthopedic surgeon takes home. A psychiatrist is the lowest paid specialist.

A front page headline in a recent New York Times nails the problem: Talk Doesn’t Pay, So Psychiatry Turns to Drug Therapy.

A psychiatrist can make $150 out of three 15 minute sessions with a patient followed by prescription, but only $90 for a 45 minute talk consultation. A prescription pad has replaced the couch.

A visit to the shrink has become a brief chat, a prescription, and you’re out of there. Many of the nation’s 48,000 psychiatrists no longer provide talk therapy. Instead, it’s a 15 minute session with a prescription adjustment.

The situation is similar for primary care physicians. Only the visit may be even shorter, 10 minutes or less. As Steven Sharfstein, a psychiatrist who serves as president and CEO of the Sheppard Pratt Health System, Maryland’s largest behavioral health system, says of a psychiatrist’s practice, “It’s a practice very reminiscent of primary care. They check up on people, pull out the prescription pad; they order tests.”

Practice becomes all about volume. Treatment becomes a production line.

So, fewer doctors enter primary care and psychiatry. Doctors in these fields switch to other specialties, retire early, or become health care executives. More health policy types bewail the primary care shortage. Increasing numbers of onlookers say we have to re-jigger the payment system by paying “cognitive doctors” more like “proceduralists.” Critics seek to restructure the RUC (Reimbursement Update Committee), in which a specialist-dominated committee appointed by the AMA and slavishly submitted to by Medicare, sets doctors’ fees.

But there’s a huge cultural problem nobody talks about. We’re an action-oriented people. We like strong silent men of action. Talk is cheap, and we’re unwilling to pay more for it.

Americans want action – a prescription, a laboratory test, a CT or MRI, a procedure.


Something concrete. Something we can touch, feel, take, ingest, inject, point to, biopsy, grasp, identify, undergo.

Something we can share with friends and family, even if it’s a surgical scar, a pacemaker, a vascular port, a hip or knee prosthesis.

Americans get all the talk we want – from talking heads on radio and TV, from channel news shows, from the Internet, and from bloggers like me.

Other than rewarding talk and recognizing and rewarding cognitive physicians for time spent with them , we should, of course, pursue the big things. ‘

Joe Flower, a health system change guru, suggested five of these things in a recent piece in The Health Care Blog.

1. New business models – retail care, urgicare centers, free (but profitable) fee-for-service clinics, specialty clinics, bundled care organizations, onsite clinics
2. Integrated systems
3. Organizations featuring shared financial risks
4. Building a stronger primary care base
5. Applying management tools – leaner care models, benchmarking , continuous quality improvement, and checklists

I am all for these things. If Joe will forgive me, let these Flowers bloom. But in the meantime, let us pay our thinkers and talkers, our cognitive doctors, more.

Richard Reece is the author of Obama, Doctors, and Health Reform and blogs at medinnovationblog.


Alan D. Cato MD said...

Dear Dr. Reece,
I enjoyed your article entitled: Why Cognitive Doctors Need to Be Paid More, and I couldn’t agree with you more. After my retirement in 2008, I wrote a book, The Medical Profession Is Dead and the Doctor Is “Critically ill!” I primarily had hoped it would be helpful to the naïve health care consumers, and be of use as a road map for politicians. To date, however, most of its sales have been to physicians and other medical providers. While you may not agree with every premise explored, I think most of it would resonate as pertinent and truthful. I hope you will give it a look at its site, on Amazon Should you decide to read it, I would suggest beginning with Chapters 4 &5. The following excerpt from the book is particularly pertinent to your article, as are several other portions of the book. Very Respectfully Yours, Alan D. Cato MD, F.A.A.F.P.


Take, for example, a patient visiting the doctor because of
headaches he has been experiencing more often than usual. A
neurologist, or an MD in primary care, can perform a thorough history
and physical exam and, with a high and acceptable degree of accuracy,
determine the headache’s cause. However, in the time required for
carrying out such a history and physical, the doctor could see two or
three additional patients, and he receives too nearly the same office
visit fee regardless the method used for arriving at the diagnosis. Even
if he uses the proper billing code for indicating a complete history and
physical exam were done, the amount awarded him for the time spent
does not equal being able to bill for an additional three patients he
might work in for the same amount of time expended performing the
complete history and physical on the one headache patient. Also, given
that the patient comes in to the doctor already expecting an MRI of the
head, as he saw ordered by the doctor on the TV medical drama last
week, and where (surprise, surprise) the patient’s headache turned out
to be due to an extremely rare and malignant brain tumor, the
physician now would have to spend an additional half-hour in
discussing, educating, and convincing the patient why no testing was
needed in his particular instance. No, it simply is more expedient and
profitable for the doctor to order the testing and move on to the next
patient. Yet, the ability to perform a proper history and physical exam,
and to process the findings through an extensive pathological and
physiological knowledge base obtained through years of medical
school education, is what enables a physician to be highly accurate in
arriving at the proper diagnosis, and to only need expensive ancillary
testing for confirming the diagnosis in a limited and select number of

Delia said...

Well, I don't really think it will work.