Health Care Reform: Revamp Reimbursement

Exactly a month ago, I wrote about how a greater availability of general internists & family physicians was associated w/lower hospitalization & mortality rates.  Call me a cynic but I suspect part of the reason for this may be due to our current (dysfunctional) reimbursement system whereby physicians are paid for doing something but not for caring for someone.

Granted, most of us went to medical school because we wanted to make a difference for the better.  Most of us did not go to medical school to get rich (although getting paid for our efforts was an added benefit).  However, somewhere along the way, starting with our indebtedness, we realized that specialists who perform procedures are remunerated dramatically more than generalists who don't perform procedures.

In fact, it's been demonstrated that generalists perform quite a bit of work each day that goes unpaid: make 24 telephone calls to patients, specialists, pharmacists & insurance companies; write 12 prescriptions (in addition to all those written during a patient visit); read 20 lab reports; review 14 consultant reports; review 11 imaging reports; and write/send 17 emails interpreting test results, consulting with other physicians, and/or advising patients.  I'm sure the specialists' day is no different or less hectic.

Yet, when it comes to remuneration, the specialist has a significant advantage over the generalist: procedures. Economics 101 defines marginal revenue as the additional income derived from selling one more unit of a good above that necessary to cover overhead.  So while most physicians do not consciously perform procedures with marginal revenue in mind, the way our remuneration system is set up, it's difficult to ignore as these procedures are priced at hundreds if not thousands of dollars.  On the other hand, for generalists to squeeze in an additional patient, we're looking at marginal revenue measured in tens of dollars per patient visit.  Plus now, we face the wrath of those patients kept waiting who now want to bill us for their time.

All this ranting & raving is my preamble to a study published last week in JAMA that concluded that 16,838 (11.6%) of 500,154 percutaneous coronary interventions (PCI) reviewed were deemed inappropriate.  At $20,000 per procedure, that's $340 million more that could have been better spent, perhaps on medications & dietary counseling & physical activity instruction to prevent clinical heart disease in the first place.  After all, previous studies published in April 2007 & August 2008 have demonstrated no benefit from PCI in addition to optimal medical therapy in stable heart disease.

Don't get me wrong.  I'm not saying we shouldn't be paid for what we do.  But I think we need to minimize the disparity in remuneration between generalists & specialists.  Also, let me be absolutely clear and point out that the majority of the inappropriate procedures occurred in a minority of facilities authorized to perform them.  In other words, most physicians are trying to do the right thing, whether they're specialists or generalists.

Still, before you agree to undergo some procedure, ask the treating specialist if it's really necessary and what difference it will make to your clinical outcome (not just an image or a lab test).  And if you have time, get a 2nd opinion.  Or at least chat with your family physician (or general internist).  Any time someone who doesn't have skin in the game says you need something done, you need it done.