Why Cognitive Doctors Need To Be Paid More

Preface: On June 3, Kevinmd.com, 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.

Anything.

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.