Getting Real About Specialists and Primary Care Doctors

Keywords - Specialists, primary care, Medicare, entitlement

Doctors do what they

are educated and

Trained  to  do.

Veteran Nurse

Roses are red,

Violets are blue,

Doctors do what

They want to do.

Whimsical verse

August 13, 2012 – I’ve always felt that strictly dividing doctors into specialists and primary care practitioners is an artificial distinction that doesn’t hold water in the real world.

The truth is that specialists practice some primary care, and primary care doctors practice some specialty care.  There is a significant crossover. Both have a common educational background and understand needs of each other and patients.

Most medical specialists have initial  training in general internal medicine, and most generalists have been exposed to medical and surgical thinking.

The financial deck is stacked against primary care. Medicare approves the RUC (Rembursement Update Committee codes, which favor specialist.  Specialists dominate medical school faculties, from which medical students pick their mentors and heroes.  Hospitals favor specialists, who supply the bulk of their revenues. Americans are a specialist-oriented specialists. Among seniors,  a study indicates those with chronic illness see seven doctors – six of whom are specialists.

Reformers keep saying we must expand our primary care base – by paying generalists more, by acknowledging that primary care doctors require  broader knowledge than specialists, by narrowing the payment gap between specialists and generalists, by opening  more medical schools, some devoted entirely to primary care; and by recruiting and rewarding medical students who say they want to enter primary care in physician short areas

All of these efforts are to be commended.  As for me, I am four square behind the primary care renaissance . But let’s get real. Solo and small group primary care is on the decline.  As much as we lament the passage of the Marcus Wellby era,  it is gone and not likely to be reborn.

Americans prefer specialists.  This is not new.  As Alfred North Whitehead (1861-1947) observed in Science and the Modern World, 

"Another great fact confronting the modern world is  the method of training professionals who specialize in particulary regions  of thought withig their respective limitations of subject..This situtation has its dangers. It produces mind in a groove.”

As cynics are fond of noting, “Specialists no more and more about less and less, until they know everything about nothing.”  I am not one of these cynics.  I believe specialists and generalists know more and more about more and more, and where the lines of specialists and generalists intersect.

The American people know this.  So do most doctors this brief article from the Washington Post attests.

More Than a Third of Our Primary Care is Delivered by Specialty Doctors

Sarah Kliff on August 22, 2012

“ Under reasons our health care system is expensive: 41 percent of our most basic health care needs, the fevers and colds we all get, are taken care of by higher-paid specialty doctors.”

“Mount Sinai’s Minal Kale lead a team of researchers that combed through data on more than 20,000 doctor visits in 1999 and 2007. All of it had information on why the individual turned up at the doctor’s office, whether it was a runny nose (not so serious) or a heart attack (decidedly more serious).”

“Their results, just published in the Archives of Internal Medicine: 59 percent of those with primary care needs, the people in the runny nose group, were seen by a primary care doctor. Forty-one percent sought out care at a specialist.

“To be fair, some people went to specialty doctors who tend to handle a heavy primary care case load such as gynecologists and internal medicine physicians. Exclude those two groups and you still have 27 percent of primary care appointments happening in specialty offices.”

“ ‘Patients have been shown to prefer specialist physician care and believe that specialists are better able to treat specific conditions,’ Kale and his colleagues write. ‘These preferences and beliefs may drive some patients to seek all of their care from specialists, including basic primary care services.’ ”

“They may also drive up prices: Andrew Seaman points out a 2010 study finding that primary care doctors earn a $69 hourly rate, compared to the $92 per hour and $85 per hour that surgeons and ob-gyns earn, respectively.”

Tweet:  Of Americans requiring primary care,  59% are seen by generalists and 41% by specialists,  indicating many specialists practice some primary care.

                                                                                                             

 

Fee-for-Service -  The Solution and Not the Problem to Lower Health Costs

Keywords -   Fee-for-service,  health costs,  Medicare, Mediscare, physician incomes, premiums

To doubt everything or to believe everything are two equally convenient solutions; both dispense with the necessity of reflection.

Bertrand Russell (1872-1970). Science and Method (1913)

August 23, 2012 – President Ronald Reagan is famous for saying, “Government is the problem and not the solution.” I  will not be famous for saying, “Fee-for-service  is not the problem but the solution.”

Actually I am not the first to say it.   Twila Brase, president of the Citizens Council for Health Freedoms (CCHF) said it in the organization’s eNews newsletter.  I had not previously heard of CCHF, but that’s all right.  I liked what she said.

She says the real problem is third party payment, whereby health plans are paid not the physician, and where 3^rd parties “make out like bandits.”

She explains that under 3^rd party arrangements,

·         Physician incomes dropped by 7% from 1995 to 2003, and even more since (Obamacare promises to drop them 40% over the next decade).

·         For business, health benefit costs per employee will rise 7.2% this year (a big reason  why national business organizations like the National Federation of Indpendent Business (NFIB) and the Chamber of Commerce oppose Obamacare)

·         Premiums under Obamacare will rise up to 30% (Obama promisded a reduction of premiums of $2500 per family by 2016; instead a rise of $2500 is projected).

If you are bewitched, bothered, and bewildered by these figures, remember the culprit here mind may be  3^rd party administration costs and the bureaucracy required to impose and respond . Together they make up to 40% of health costs costs.

Remember too that  the government is involved.  Government has to account for every penny spent on entitlements with protocols. documentation, and regulations.  According to David Brooks in a New York Times), "A Guide for the Perplexed,"  entitlement spending  in 1962 accounted for 14% of every government dollar spent , today it makes up 47%, and by 2030 it  will be 61%. There will be no room left for spending on education, roads, and defense.

The solution may reside in government spending a fixed dollar amount for health benefits.   Government  will define the package of benefits.  Medicare and competing health plans will bid on the package. Government will give  seniors a payment equal to the 2^nd lowest bid, and patients will  pay out of their accounts.

This could all be done on a fee-for-service basis.   Patients would pay doctors out of their accounts, and could feel free to negotiate with physicians for  the lowest price. Physicians, meanwhile, could lower their fees.  Among medical practices,  it is known that about 50% of overhead is due to 3^rd party administrative expenses, and fees could be proportionally lowered to compete with other physicians.   Cash-only practices now often charge 50% less than private plans, and even less than Medicare and Medicaid because there is no 3rd party involved and overhead is less.

The government elite does not agree market-competition will reduce costs.  Peter Orzag, former director of the office of management and budget under Obama,  calls the idea of competition lowering costs the “competition fairy.”  And the big health plans with the following revenues and number of employees -  United Health Group, $101 billion, 99,000, WellPoint $61 billion, 37,900; Humana, $36.8 billio, 40,000; Aetna, $33.9 billion, 33.300; Cigna, $22 billion, 31,400 – would lobby furiously against a diminished role for 3^rd party health plans.  Health plans  will not go silent into that good night of no 3rd party administration with price setting.

Oh,  well,  for me the thought of 3^rd parties as the problem and not the solution,  and fee-for service as the solution and not the problem,  has a bewitching, bothered, and bewildering simplicity ring to it. Unfortunately, as H.L. Mencken (1880-1956) observed, “ For every complex problem, there is an answer that is clear, simple, and wrong.” 

Tweet: Physician fee-for-service payments rather than 3rd party payments would be cheaper and more convenient and would lower health costs.

 

Medicare and the Other Side of the Physician Fee-For-Service Controversy

Keywords - Physicians, fee-for-service, accountable care organizatins,  Medicare, savings, independent payment advisory board, physician payment

Medicare’s design was based on the historical demands of the medical profession for “fee-for-service” (FFS) payment: “free choice of treatment” without accountability for quality and outcomes; Medicare to pay the doctor’s “usual and customary” fees; solo practice and physician autonomy (without coordination or teamwork).

FFS means more money to the doctor for doing more and more costly services. The doctor who prevents the patient’s costly medical problem or solves it quickly and inexpensively does not prosper in this model.

Alain Enthoven and Alan Glaseroff, “Bringing Medicine into the Twenty-First Century,” Health Affairs Blog, August 20, 2012

The uncapped entitlement and distorted fee-for-service structure of traditional Medicare are major causes of the rapid rise in program spending. Poorly targeted fee-for-service payments promote the use of more — and more expensive — services, delivered in a fragmented and uncoordinated environment. The result has been higher spending and poorer patient outcomes.

Joseph Antos, Mark Pauly, and Gail Wilensky, “Bending  the Cost Curve Through Market-Based Incentives, “ New England Journal of Medicine, August 1, 2012

August 21, 2012 -  To policy wonks,  bending  down the cost  curve of Medicare is simple.

·         End fee-for-service

·         Pay doctors a fixed amount for episodes of care or for total care

·         Corral doctors into accountable care organizations, place them on fixed budgets,  bundle hospital-and doctor bills, put them at financial risk if they exceed budgets.

·         Give patients, doctors, and health plans  a defined benefit, a fixed amount, or a premium-support, that you will pay them

·         Have the president appoint a 15 member Independent Payment Advisory Board to dictate what to pay doctors.

A Problematic Scenario

For doctors this scenario poses a problem.  Doctors are keenly aware, for instance, that the so-called $716 billion in "savings" in Obamacare comes in the form of 40% cuts in hospital and physician in the name of  increased "efficiencies" amd enhanced "outcomes," over which they often have no control.

Doctors distrust Medicare as a payment source. They think of Medicare as a lousy business partner.  In one way or another –  approving the Resource Update Committee  (RUC) recommendations or imposing  arbitrary fees for services and procedures, Medicare now sets Medicare fee-for-service fees

These fees often bear  little relationship between physician time and skills needed  to get the work done.  Medicaid now  pays on average 56% of private health plan fees and Medicare 81% of these fees.

As James Merritt, Joseph Hawkins, and Phillip Miller explained in Merritt, Hawkins & Associates Guide to Physician Recruiting in 2007.

“Physicians are different from other professions by virtue of the ground rules of contemporary medicine. The ground rules are largely determined by the way in which medical services are paid for in the United States today. Medicare sets physician payment rates for a wide range of services categorized as Diagnostic Related Groups (DRGS). An orthopedic surgeon might be reimbursed $500 by Medicare for setting a simple bone fracture. Private insurance companies often set their reimbursement rates based on what Medicare pays.’

“The point is that physicians rarely set their own fees. The money reimbursed to them for services may have little or no relation to their cost of doing businesses. What can be more aggravating is that sometimes third parties also dictate what physicians can or can’t do for their patients, by declining to pay for services physicians may believe their patients need.”

“This is not the environment most of us work in. There is no “third party” barrier between the lawyer, the accountant, the computer programmer, the plumber, the mechanic and his or her coolants. They all set a fee, perform a service, and are paid directly by the person for whom they did the work.

Imagine a plumber who fixes a pipe for a fee set by the government – a fee that does not meet the cost of his tools. The plumber then submits a bill- not to his client, but to an agency or insurance company. The agency or company then declines to pay the bill on the grounds that they do not cover this particular service under those particular circumstances.”

“It would be no surprise, under these conditions, plumbers became a generally cranky group – especially if they had to complete 11 to 15 years of post-college training to become plumbers.”

Something Rotten

Something is rotten in the state of Medicare, for example, when a physician stays up all night to save a patient with ventricular arrest, submits a bill of $1500, and receives a Medicare payment of $160.

Yet it is not uncommon for physicians to receive 1/10 to ½ of the amount of the bill they submit.    Medicare  technocrats arbitrarily, capriciously,  and unilaterally pay what  they want to pay.   There is no recourse – no appeal –  physicians must simply shrug their shoulders and bear the financial pain.

The public  is generally unaware of the discrepancy  between work done and amount paid.   When a patient receives a bill,  it lists what the doctor charged and what Medicare paid.  Patients have commented to me they have noted the difference, but they aren’t paying themselves so what the hell.   It’s no money out of their pocket and no skin off their back.

But doctors notice.  A physician friend of mine told me the story of his wife who suffered from uncontrolled renal –based hypertension which had induced heart failure.   The ER physician spent 4 hours turning the situation around.  He submitted a bill for $677.00 and was paid $324.83,  48% of wht he requested.

Yet the notion persists among wonks that “open-ended fee-for-service” with the incentive to do more of everything  is the root of all health inflation evil – that and the lack of “coordinated care,”  “accountability for outcomes,”  and rewards for “quality and efficiency.”

I suppose this all makes sense to wonks in their distant offices, accountants with their green eyeshades, and Washington-based Medicare technocrats, but it does not make sense to physicians in the trenches who spend 11 years to 15 years learning and mastering their skills.    The discrepancy contributes to the looming doctor shortage.

Medicare has created what one physician described at a Pettifogging Physician Payment System (PPPS)that  pays petty amounts under cover of an impenetrable bureaucratic fog.   PPPS also creates a practice environment from which physicians are fleeing by refusing to accept new Medicare patients,  creating cash -only practices,  forming concierge practices,  and retiring and quitting.  Why does the FFS controversy matter?  Because the controversy  produces conditions that place America on the verge of a monumental physician shortage.

Tweet:  There is often little relationship  between the time doctors spend treating patients and what Medicare pays for fee-for-service.

What President Obama May or May Not  Choose to Understand about American Culture

Keywords - culture, American dream, entrepreneur, trickle-down, capitalism, conservative, freedom,  fair share

The essence of a self-reliant and autonomous culture is an unshakable egoism.

H.L. Mencken (1880-1956), Prejudices: Second Series

I have made it my earnest concern not to laugh at, nor to deplore nor to detest, but to understand, the actions of human beings.

Spinoza (1632-1677), Tractatus Politicus

August 20, 2012 - If I had a piece of advice to offer President Obama,  it would be for him to understand American cultural values better. He seems not to grasp what drives Americans and what they seek.   These values may not match his values,  but if he chooses to ignore them, he does so at his re-election risk.

·         Americans  are a conservative-leaning  lot in a center-right nation (41% consider themselves conservative, 36% moderate,  and 21% liberal.)

·         They are egotistical in that they believe in themselves and in personal independence– in self-reliance and autonomy rather than government dependency.

·         They believe in the American dream – that they too can become rich if they work hard enough to climb to the top of the hill.

·         They are not big fans of  trickle-down capitalism, but they  are adamantly opposed to  trickle-down mandates from government.

·         They believe that someone who succeeds in business or in any other endeavor “built that” on their own initiative  not because of government support, e.g., the honor student who achieves did it on his/her own not because of the bus riding  on government roads  that brought students to school.

·         They believe in equal opportunities for everyone – but not in equal outcomes for everyone.

·         They believe government should serve as an impartial catalyst not as a crony referee who picks winners and losers.

·         They believe people on the ground, on the streets, and in the workplace know as much or more than government experts about what people want and what causes people to achieve and move up the social and enterprise  scale.

·         They think of America as a  bottom-up society, where the truly important innovations and trends, emanate locally, i.e. great ideas  trickle-up from the bottom that rather than trickle -down from the top. To paraphrase, Tip O’Neil  “All innovations and trends  are local.” Think globally, but act locally.

• Grassroots Americams do not like to be sneered at, detested, or deplored or laughed at for firmly held beliefs – e.g.  those 41% of Americans who support the Tea Party do not like to be labeled as “right- wing nuts” for “wanting to take their country back” to its founding constitutional principles.

·         They believe a free people have the power to change things, as they did in the November 2010 elections. They may do so again in the November 2012 elections.

·         They continue to come to America and stay in America because of its reputation and promise of free enterprise and individual liberties not because government offers everyone a “fair share” of its blessings.

·         “Fair share” collectivism should not be equated with “laissez faire” capitalism.

·         They believe in “social justice” but not at the price of giving up their liberties and moving to the beat of the government drummer.

·         Many, certainly not all, distrust big government and believe in the Jeffersonian concept that the government that governs least governs best.

·         They are “progressive”  in the sense that that they believe their children and their grandchildren should be better off  than they are.

·         They believe the tide of a rising prosperity and full-time work with honest  people paying  honest taxes lifts all boats.

• They believe every form of economic activity requires an entrepreneur - someone to have the idea, to hire the labor, to borrow capital, to buy the materials, to take the inherent risk, and to pursue a profit with the avoidance of loss; government, on the other hand, need not take a risk, earn a profit, or avoid loss: that is the nature of the beast.

·         In health care, they feel capable of making their own health care decisions, of equal opportunity access to high technologies and other medical wonders, of public/private  payment systems with choice, and of clinical decisions by doctors rather than bureaucrats bearing algorithms deciding what is best for them.

Tweet:   President Obama may not understand or appreciate American cultural values, a reason his policies may be in trouble and his re-election is in doubt.

A Silly Medicare Policy: Penalizing Hospital for 30 Day Readmissions

Medicare needs to remember that people are not cars.  They seem to treat hospitals like automobile repair shops. In other words, you should be able to change the tire, send them on their  way and not see them for another 5,000 miles.

Curt Schroeder,  Head of the Delaware Valley Healthcare Council,  quoted in August 17, 2012 Kaiser  Health News

August 19, 2012 -   “Silly,” as defined in my dictionary, is “ridiculous,  lacking common sense.”

Among the silly aspects of current Medicare policy are these.

One,  that taking $716 billion out of Medicare trust fund as part of Obamacare does not change “Medicare as we know it.”

Two, that financing Medicare  hospitals and physicians by cutting their revenues and incomes by roughly  40%  over the next decade “saves” Medicare and extends “access.”

Three, that rising hospital readmission rates are the fault of hospital and physician careless discharge planning and should be punished by decreasing hospital Medicare funding.

Four, that hospitals and doctors  should be able to completely control patient behavior  and patient’s chronic diseases once the patients are outside their reach.

Medicare patients, as Curt Schroeder, head of the Delaware Valley Healthcare Council, reminds us are not like cars.

Medicare patients are human beings.  You cannot repair  their aging  engines,  replace their degenerative spare  parts,  change their batteries,   pump up their deflated tires, trade them in for a new model, or even give them a spring tune-up, especially when they have left the repair shop and return to  to conditions in their former enviroment that bright them to the repair shopt.    Patients’ diseases and their ages never leave them, even after the leave the hospital.  Hospitals should not be penalized for that reality.  Health reform cannot  guarantee against hospital readmissions.

Tweet: Among the “silly” and misguided aspects of Medicare policies is penalizing hospitals for 30 day readmissions.

History of Health Reform in a Center-Right Nation

According to the most recent Gallup poll, 41 percent of Americans self-identify as conservatives, 36% as moderate, and 21 percent as liberal.

Peter Wehner, “U.S. Remains a Center-Right Country,”Commentary Magazine, July-August, 2012

Don’t know much about history

Don’t know much about biology

Don’t know much about geography

Lyrics, “What a Wonderful World,” 1959

August 18, 2012 –  If you do not know much about the history of health reform in the U.S.,  I recommend you read  Jonathan Oberlander’s’ “Unfinished Journey – A Century of Health Reform in the United States” (New England Journal of Medicine, August 16, 2012). 

Dr. Oberlander is an unabashed Obamacare supporter.  For him, an alternative title might read, “A Century of Health Reform Disappointment in a Conservative Nation.”  

Oberlander’s position  is reflected in this statement, “U.S. Policy is a story of progress – but also abject failure." His references are all written by Obamacare supporters, and his  language near the end of his article reveal his bias,”If Mitt Romney wins the presidency, however, and Republican secure majorities in the House and Senate,  major provisions of the law could be overturned… U.S. health policy stands at a crossroads. Will we continue down the path of reform or move backward?”

Oberlander’s article is well worth reading.  It highlights the history of health reform . It lays out  21 milestones of  health reform proposals-   progressive proposals, legislative triumphs,  and legislative failures.

1.      1915 – American Association of Labor Legislation proposes compulsory health insurance; model bills are later introduced  in several states but fail to pass.
2.      1943 -Senators Robert Wagner and James Murray and Congressman John Dingell introduce legislation to establish national health insurance through Social Security.

3.      1945 – Harry S Truman becomes first U.S. President to propose national health insurance; legislation fails to pass.

4.      1946 – Congress passes the Hill-Burton Act to fund hospital construction.

5.      1951- Truman administration proposes federal health insurance for elderly Social Security beneficiaries.

6.      1965 – Congress enacts Medicare and Medicaid.

7.      1971- President Richard Nixon announces health reform plan requiring employers to insure workers and subsidize coverage of lower income Americans; it does not pass. 

8.      1972 – Medicare is expanded to include persons with end-stage renal disease and permanent disabilities. 

9.      1973- HMO Act encourages devlopment of health maintinance  organizations.

10.  1977- President Jimmy Carter proposes a program to contain hospital costs; bill is defeated in Congress. 

11.  1983- Medicare adopts prospective payment for hospitals.

12.  1985- Consolidated Omnibus Budget Reconciliation Act (COBRA) allows workers who lose employer health insurance due to job loss to continue coverage up to 18 months, paying premiums themselves.

13.  1986 – Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to screen and stabilized all patients seeking emergency care, regardless of insurance status or ability to pay.

14.  1989 – Medicare adopts a physician fee schedule.

15.  1990 – COBRA requires state Medicaid programs to cover children 6 to 18 years living in families with incomes below the poverty level, culminating in series of Medicaid expansions that began in 1984.

16.  1993 – President Bill Clinton proposes universal health insurance, but Health Security Act fails to pass Congress.

17.  1996 – Health Insurance Portability and Accountability Act (HIPPA) limits employers’ ability to exclude pre-existing coverage for new employees.\

18.  1997 – Congress enacts the State Children’s Health Insurance Program (SCHIP)

19.  2003 – Medicare Modernization ACT +(MMA) adds prescription drug coverage to program and creates tax-preferred Heath Savings  Accounts to be paired with high-deductible health insurance 

20.  2010 – Congress enacts Patient Protection and Affordable Care Act (ACA)

21.  2012 – Supreme Court rules that ACA is constitutional but restricts federal government’s ability to take away funding from states that opt not  to expand Medicaid. 

Tweet:   The history of health reform in center-right America is a story of Presidential triumphs and failures leaving 20% of nonelderly uninsured.