Death of cognition

This is what you get when cognitive specialties are not reimbursed properly. Patients lose:

As long as insurance reimbursements are doled out like well-paid piece work, fields like rheumatology will depend on doctors entering the profession out of the goodness of their hearts. There will always be some of those, but how many?

Comments

Anonymous
Well, that’s certainly a rather narrowminded view of things. His daughter needs a rheumatologist, ergo rheumatologists are super important.
Somehow I suspect the people who need emergent cardiac catheterization don’t think of the physician doing it as a “cath jockey” and probably think the cardiologist should be better paid.
Anonymous
And yet no one can come up with any alternative rather than “they should be paid more”. How do they suppose we change it. Hey great diagnosis here’s your bonus. Like something of the sort is even feasable. Paid by the hour? See what that does to productivity. Labeling cardiologists a cath jockey is obviously someone that has never been in a procedure room or the OR. They think procedures magically occur and it takes neither skill nor cognitive function to do one. According to the tone of the paper anyone with a GED and 2 hours of shop class should be operating on cataracts. An Orthopedic surgeon gets paid less for a total knee arthroplasty today than they did in 1976, over 30 years later. Railing on specialist does nothing for the arguement.
Anonymous
Come on people. Just because it is an anonymous comment on the internet and you CAN be ridiculous doesn’t mean you should or that you have to.
He made a very good if limited point. He presented a problem without an effort to analyze the reason or provide a solution–which is a perfectly legitimate goal of a journalist. His point is valid the sarcasm above notwithstanding. Rheumatologists are indeed super important when your child needs one to survive. But it is worth reporting that for some odd reason, while a cardiologist or orthopedic surgeon, when needed, is available, non-procedural physician sometimes can’t be found.
It is an aberation worth calling to our attention that clearly the law of supply and demand is not working here. There is a huge unmet demand, but the supply is not arising to met it. Why? Clearly when the labor that is hardest to find is also the labor that is relatively speaking the least paid, we have and economic aberation.
Simple economics suggest that if there is a plentiful supply of labor to do a job, the pay is adequate, when the labor does not appear, the pay is inadequate. It is not my opinion or your opinion or the RVS committee’s opinion that tells us that psychiatrists are underpaid by the price-fixers relative to cardiology. We can’t tell that from relative incomes, as cardiolgy work may in fact be worth several multiples. What tells us that the differential is in fact at least in part a reflection of underpayment of psychiatry, is the fact that I can find a cardiologist within hours in the event of an emergency and weeks for routine care, while it takes 3 months to get in to see a shrink in this town. Clearly there is a price at which more people will enter psychiatry and at which they will be willing to take emergency patients–but the price fixers aren’t reaching it while they are for cardiology. You can say the shrinks are “lazy” etc etc but the fact remains that there is a compensation level at which the needed services will be provided–but it clearly isn’t being reached.
None of this has anything to do with the the intellectual difficulty of procedures. It is not rail on specialists, but a rail on a payment system is clearly by objective standards of providing an adequate supply of services does not adequately reimburse some non-procedural services. Plenty of people who didn’t even get a GED are smart enough to understand that.
Anonymous
So advocate increasing the pie, not cutting away from those providers that provide a procedural service. The second he makes the statement about caridologists and opthomologists he is railing on specialists not the payment system as you say. A cardiologist by his field alone will save more lives than a Rheumatologist or Psychiatrist. That is one simple reason to understand why their work is more valued and reimbursed better. Right or Wrong when it comes to funding psychiatry services it is at the bottom. Obviously if our society thought it was as important as cardiology there would be more of an outcry, but when budgets are cut for Medicaid, Psych services are usually the first to go. Like I said right or wrong who knows, but that’s entirely another debate. Thats why I think entirely too much time is spent on worrying about doctors salaries, here and elsewhere, when you consider 79 cents of every healthcare dollar goes to something other than physician payment. Do you think it’s excessive that an Orthopedic surgeon gets paid the same for a procedure today that they did 30 years ago.
Anonymous
Anon 12:12am,
If you think the economics of healthcare reimbursement has anything to do with the number of lives saved then anyone that works in public health should be taking home a multi-million dollar salary. Clearly, this is not the case.
Anonymous
The answer is to set your own fees, and for Medicare and other payers to state clearly to patients what they will pay toward provider bills. The balance is the patient’s responsibility, and they can choose who they want to see. Doctors will make their fees available to the public.
Do you want to see the doctor with the great reputation, who spends 30 minutes with you, and has plush office with Starbucks coffee? He costs more. Do you want to see the FMG doctor in the barrio who spends five minutes with you, has a tv with rabbit ears, and has the hard wooden benches in the waiting room? He costs less.
This is clearly the answer, at least for nonemergency care issues. Ultimately the free market will dictate prices, patients will have a choice, Medicare will remain solvent, and health insurance companies will be able to offer a wider variety of products.
Anonymous
I agree with the post immediately above regarding the most direct solution. Stop trying to set or control fees and simple economic laws will supply the full range of services that the public needs.
Most of the guys above are being suckered by the divide and conquer ploy that the folks who gave us RVS wanted, get the slaves fighting among themselves and they won’t be a threat to the masters. They are being overly sensitve and taking the comparisons in the artile as an attack on proceduralist fees.
Regarding ortho fees 30 years ago versus today, an economist would say that the comparison is irrelevant, if todays fee were not adequate for todays environment, the service would be hard to find. It is not. My father paid $1200 for a simple 4 function calculator for his engineering firm in 1972 or 73. That doesn’t mean that todays price is out of line for today.
Clearly we need to inject a dose of freedom into this highly statist sector of our economy. Let the providers set their fees, let the patients choose, and let the net individual choices about the importance of medical care determine how big “the pie” is.
The entire drive to reduce health expenditures is an artifact of third party payment and centralized control. No one says 20% is too much to spend on transportation, because corportate American makes the money. No one says we spend too much on entertainment–they push us to spend more. Is cardiology more important than psychiattry? That is purely for each individual to decide, where competent. Actually I stopped certain cardiac drugs for the sake of my mental health because the had me feeling so bad that I didn’t care whether I lived or died. I choose quality and the health of my soul over life expectancy. Should that value be decided by an RVS committee? By a bureaucrat? By blogers? Not for a free people.
BTW, I had no trouble finding a good cardiologist, finding a good psychiatrist was a different matter. When I did find one, I told him that his fees were too low and I wanted to pay more. He wouldn’t take the extra but was glad to see green Ben Franklins and worked me in.
Happyman
anon 8:28 says “Labeling cardiologists a cath jockey is obviously someone that has never been in a procedure room or the OR. They think procedures magically occur and it takes neither skill nor cognitive function to do one. “
I have been in a cath lab & the OR many times, and for some doctors I agree with that label. There is definitely manual skill involved, but like any other percutaneous procedure, cardiac cath is not magic & can be learned & mastered with practice.
anon 12:12 – the “saving lives” point is ridiculous:
There is definitely financial incentive to do procedures, and recent research suggests that immediate cath doesn’t even improve outcomes over drugs in many cases. It’s cardiology’s dirty little secret that there are tons of unnecessary caths & stents, when drugs and/or surgery are the way to go.
As far as saving lives, should cops & firefighters be making millions? What about teachers and pediatric rheumatologists who shape lives with much more potential added to qaly (“Quality-Adjusted Life Years”)
compared to the 85-yr-old getting his third cardiac cath?
It is just so naive to attribute such inherent altruism to the interventional cardiologist. Attitudes like that are what drive reimbursements up for them, & down for everybody else (along with the powerful lobbies of the drug/stent industry & specialists).
Society is getting exactly what they’re asking for – lots of procedures to perform of dubious efficacy, with nobody to advise their lack of necessity.
Anonymous
If this was the only problem with our system in that the overabundace of procedures are mostly unneeded. Wouldn’t it be hard for a cardiologist or specialist to find a job. Since all of these are unneeded, you think there would be extreme competition between providers. Cardiologists would be slashing prices and setting up a mobile cath lab next to the funnel cake stand trying to drum up business, to eek out a living, but that is not even close to the truth. Most specialists only have to pick their location and the jobs are abundant. The diseased population is there, however it is treated (medically or by procedures). Could it be that there is a willing populus with no personal responsibility. We have the fattest and laziest population on the planet, yet people are quick to compare us to other countries and lament the amount of money we spend. Could it be that other countries are healthier not because of the systems they have but they actually don’t feel the need to order a supersize fries, double cheeseburger and a 64 oz Coke with every meal. Attribute it to the Burger King generation. “Have it your way” I don’t want to diet, give me a pill for my heart disease and diabetes. I don’t want to exercise just give me a total joint replacement in 5 years.
Happyman
“Cardiologists would be slashing prices and setting up a mobile cath lab next to the funnel cake stand trying to drum up business”
Duh, from someone actually IN medicine, let me tell you that the patient is detached from the payment equation altogether, and thus it is an artificial market.
Anonymous
Its not as artificial as you think. Patients do actually have a say in whether a procedure is done or not. The patient may be disconnected from the payment, but it doesn’t stop patients from demanding to have procedures done. Last time I checked patients weren’t being paraded to the O.R. at gunpoint and being forced to have an operation.
Happyman
here’s the typical scenario:
1-cardiologist wears a white coat, has a model of a heart on his desk, credentials on his wall
shows a patient a picture of some coronary arteries, stating “I suspect you have a blockage here, here, and here; we must go in and open them up, or you may have a massive heart attack & die at any moment – have you been having chest pains or palpitations?” (EVERYONE seeing him is having one or the other, or they wouldn’t be there in the first place)
3- patient is freaked out by the probability of imminent death, and impressed at the crystal ball this guy seemingly has – “he’s a GREAT doctor”
patients have say in whether procedures are done??? my ass. the “cards” are stacked against ‘em.
Anonymous
Abolish the entire notion of Medicare “assignment.” It is an idea that does not work any more than any other price-fixing scheme works, and for the same reasons. Uncouple the Medicare price limits and abolish the required opt-out requirement for private contracting. Allow doctors to offer whatever services or procedures they want at the prices they feel they want to charge, regardless of what Medicare authorizes. Allow doctors to either accept payments partially from Medicare, i.e. the patient pays only the balance and the doctor bears the administrative burdens and expense of filing, or not and let the inconvenience rest on the patient, perhaps for a lower price.
With a fair pricing scheme where payers like Medicare cannot thwart normal market mechanisms, there won’t be so many people crying about a dearth of psychiatrists. I don’t expect psychiatrists will command the same wages as interventional cardiologists, but their services will be available if they are allowed to charge what they think they are worth. And yes, someone who has to get out of bed or come in on a weekend should be well within their rights to see service at those times as worth much more than those during weekday working hours. (If you called your plumber to do work at your home on a Sunday, whatever the reason, there would be no discussion about premium charges.)
The dichotomy between cognitive and procedural (does that imply something less mindful?) is a false one; in the end, they are all CPT codes and all can be priced according to their demand. The only requirement I can suggest is that doctors post their list prices publicly. Discounts should be freely negotiable.
Anonymous
Happyman,
If that is your opinion on your local cardiologist. Do you and your patient a favor and don’t refer to him. He or she doesn’t need your charity. Take care of the angina and palpitations yourself, because obviously the cardiologist is not looking out for anyone other than himself in your world. The outcomes are no better right, so put your money where your mouth is and don’t send anyone out. You might as well tell your patients with cataracts that vision is overrated and those with torn ACLs and Rotator Cuffs to give up exercise, that’s overrated too. If you do this time and time again you will see the market correction you desire, if your patients don’t rebel in the meantime.
Anonymous
How come every time Kevin thinks he is losing money, he has to couch it in “patients lose”?
scalpel
Dermatomyositis is not that difficult of a diagnosis to make, and prescribing steroids for the condition isn’t exactly brain surgery either.
underappreciated internist
Well, scalpel just made the point, not being a rheumatologist or internist, his hypothetical advice is tantamount to malpractice.
The patient deserves a malignancy work-up. Of course, any old doc could just have given him the steroids, right scalpel?
scalpel
I am in fact a board-certified internist.
Happyman
anon 10:38-
I refer even very elderly patients for cataract surgery all the time, as this adds to quality-of-life at almost any age.
I also don’t hesitate to refer patients who have a sudden unexplainable change in ambulation to an orthopod.
Practicing medicine (esp. primary care) is about applying judgment for the best treatment of the patient. For some, however, this his devolved into running patients through an UNNECESSARY mill of procedures. That is the point.
I’m not saying that nobody should ever be seen by a cardiologist, I’m sorry you misunderstood that. I am saying, however, that there is a TREMENDOUS financial incentive to do procedures, and you must be blind or stupid to not acknowledge that that influences behavior.
And I am somewhat judicious in my referral to specialists, especially to ones I know will run my patients through their in-house procedure mill, then give me no answer in how to manage them.
Anonymous
I sure wish I could keep “my” patients from running through the primary care eval and treatment mill they have to navigate before their PCP magnanimously gives up, admits defeat and sends the patient to someone who can figure out the problem. (But since I’m on the other end of the referral trail, I don’t have that luxury.)
And I can assure you Happyman, in MOST instances that does NOT entail those dreaded (brrrrr) PROCEDURES. It entails application of those congitive principles which Kevin seems to feel is the exclusive purview of non-surgical, non-procedural doctors.
If you’ve seen your share of “Cath Jockeys,” rest assured” that we lowly “proceduralists” have seen our share of “Pen Jockeys” in primary care.
Anonymous
Happy this guy is simply hilarious. His next line will be how he gets so many stupid referrals from those moronic PCP’s who can’t think for themselves.
PS: Back when I was a hospitalist I never had a problem getting a ortho or cards c/s. However, getting a rheum c/s was like fishing in the desert. I think anybody who minimizes rheum docs doesn’t have a good handle on how difficult some of the diseases that fall in their realm can be to diagnose and manage.
Anonymous
Dear Moron 4:50 PM, Where in my post was I minimzing the work of rheumatologists? I was addressing the obvious disdain that Happyman has for CERTAIN cardiologists,but which has become generalized in this thread to all non-invasive specialists. My post was a mirror counterpart to his. you can argue your point, but to disrespect entire groups of individual practitioners is silly. Mine clearly struck a nerve in you. Happy’s in mine.
Like they say in the computer world: RTFM
Anonymous
First of all anon 4:50 I did not call you a moron, rather you are hilarious. Who is disrespecting who?
Secondly
re:”but to disrespect entire groups of individual practitioners is silly”
Let’s look at your other previous post.
“I sure wish I could keep “my” patients from running through the primary care eval and treatment mill they have to navigate before their PCP magnanimously gives up, admits defeat and sends the patient to someone who can figure out the problem.”
“… rest assured” that we lowly “proceduralists” have seen our share of “Pen Jockeys” in primary care.”
If those lines are dripping with sarcasm and disdain towards our PCP associates than I don’t know what is. You see anon, the difference between you and me is that I used to be a internist before I subspecialized. I’ve walked in happy’s shoes. I (unlike you) know exactly what he is talking about. I am personally very understanding of PCP’s plight and always keep them in the loop with THEIR patients (and since they are the PCP then THEY (not me or YOU) are the primary doctor). Also, when I was a PCP, I tried to keep MY patient’s away from the “cath jockey’s” and “scope jockey’s” rather referring to those subspecialists who thought through the need for procedures. If you don’t think “cath/scope jockeys” don’t exist than you don;t practice medicne in the USA.
Lastly; this thread was about the lack of pediatric rheumatolgist’s at all in a major city, yet several (maybe not you) have minimized their input. When it comes to putting the complexities of some rheumatologic diagnosis and treatment together I will always tip my hat to them an their COGNATIVE skills.
Anonymous
I do tend to go blind and stupid, being well endowed does that to you with the lack of blood flow to the brain and all. I’m sure you and the other cognitive professions have no problem with that.
What were we talking about. Sorry, I must have blacked out. Oh yeah, you are selling yourself short. I have faith in you happyman, why are sending you patients to orthopods and cardiologist at all, when you can be curing everyone and everything with your mind. You are lamenting the same financial incentive that every doctor in this country goes through in our system. It knows no single specialty. See more patients in a day and spend less time with each of them, ever heard of physicians doing that? More procedures equals more income. More patients seen equals more income. As the other poster stated there are lots of “pen jockeys” out there to. No field is immune from the “incentives” of the system.
Anonymous
Labeling someone a “cath or scope jockey”- OK
Labeling someone a “pen jockey”- Wrong
Just so we are clear.
Happyman
if being a “pen jockey” is the way to go, medicine subspecialists (e.g. cardiology, gi) can do just that, since they are mostly boarded in internal medicine.
Ah, but they don’t. why is that, do you think? In fact, last time I referred to a cardiologist he called me back and said “you want me to see this guy or you just want an echo?”
I don’t mean to start a war between PCP’s & procedural specialists – all I am saying is that ANY honest physician will acknowledge that the likelihood of having a procedure done on you depends, at least in part, on the financial rewards related to doing so.
Perhaps specialists should be capitated (before you get in a huff, yes, at a higher rate than PCPs to account for the add’l training & expertise).
Happyman
anon 7:32-
please again read my post of 1:44pm – I refer to ortho all the time, and I never said I can treat someone’s fracture with my mind.
you sound like a friggin’ dumbass inexperienced med student doing an ortho rotation or something. clearly not treating patients at an attending level by the way you spout bs. i guess we’ll never find out “anon”
Anonymous
Damn so sensitive. I guess you mean by “attending level” you mean calling people stupid and dumbass behind a computer. Besides only a couple of the posts are mine, but I like how the other guy thinks. No med student here, just an orthopedic trauma surgeon rodding unneccessary femurs and doing unneeded washouts at 3:00 A.M. Most of the time patients want to see me in spite of the bs I spout as you state, especially when they have a broken acetabulum and no one else will take care of.
Don’t ignore that patients drive the likelyhood of a procedure being done. Patients would rather have a screw for a nondisplaced scaphoid than be in a cast for 3 months or have a Jones fracture fixed rather than be nonweightbearing in a cast for 6 weeks. The same incentives that you despise are in play for PCPs look at the rise of the retail clinic and the fight going on to prevent them. In the current state the patient is revenue whether its a neanderthal procedure or cosmopolitan office visit the motives are the same. Do more make more. Every minute chopped off of a visit is more time to schedule another. Captitated the patient is the expense not a good way to think about your care. “This naprosyn should cure your shoulder if it doesn’t I just can’t help you.” Pay everyone by the hour laziness prevails. No one will be happy with whatever system or allocation we have.

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