Health reform needs to end fee for service medicine

As the health reform debate rages on, the central issue of how to improve care while reducing costs remains unaddressed.

Fee-for-service has reduced doctors to assembly line pieceworkers, paid by the office visit and procedure rather than by effectiveness of treatment. The result is an inefficient, costly and dangerous system. It is not unusual for a five minute office visit, which excludes clinical examination or note taking. Many patients/consumers can be seen in an hour. Time is money. And let us not forget those insidious, endless co-pays. The perfect storm is gathering as health care costs are now 17.3% of the GDP and rising.

Doctors and patients once had a close, almost familial, relationship lasting decades; a relationship seen in the success of the Veterans Administration, whose doctors are salaried. Today, seeing a doctor is short and impersonal as we shuttle from one “provider” to the next. How can this approach serve a patient better than a doctor engaging in dialogue and a thorough clinical examination?

I recently experienced how fee-for-service “healthcare” works up close, and I would like to share my own experiences here.

Two years ago I fell down stairs and was whisked off to a major New York hospital. I was seen by an ER doctor, not an orthopedist, which the injury clearly warranted. X-rays were taken, I was given a soft leg brace and a cane and discharged. The $35 cab ride home was the first of many costs to follow.

The following week I saw an orthopedist recommended by the hospital — one of only two names offered, the other being their Chief of Orthopedics. A father and son duo. The young doctor briefly touched my leg, announced that I had torn a calf muscle and would be fine in six weeks. His specialty knee replacement, and since I didn’t need a knee replacement, I was dismissed in under ten minutes with no follow up visit recommended.

Needless to say, I was not fine in six weeks. I saw another orthopedist who took X-rays, administered a cortisone shot and prescribed physical therapy at an office he owned, without an examination of the injured leg. At my next visit, I insisted on an MRI, and the doctor was surprised to find I had a torn ACL and meniscus; he thought I had simply a small knee tear.

During my visits, this doctor would simultaneously see five patients and was constantly interrupted. Back and forth he went, and I marveled how he could even remember each person’s issues.

It was now time for orthopedist number three. This doctor prescribed additional physical therapy and recommended I see a physiatrist at her hospital’s spine institute, thinking my leg problems were caused by my back. She couldn’t understand my continued difficulty walking after so many months.

The physiatrist was seen, two MRI’s of the back and cervical spine taken and a cortisone shot arranged, without any warning of its dangers (osteoporosis and stress fractures) or its 50% failure rate. The physiatrist diagnosed two herniated discs, which I did not have, then suggested another cortisone shot higher up in my back. The MRIs showed stenosis of the spine suspected as the root of my problem walking.

The hospital was paid $3,200 for the cortisone shot. A puncture of the skin, an injection is considered surgery and paid accordingly. I refused to pay a $100 deductible, instead expressing my displeasure at my treatment in a letter to the president of the hospital. So far, no response.

Since then, I have seen a spinal neurosurgeon who recommended two back surgeries, though I had no back pain. The first surgery has a 20% failure rate; the second surgery would fuse discs and add a rod to my back. No explanation was given as to why a second surgery was a possibility.

I have also seen three neurologists and was administered a $1,500 EMG test with no negative results, and have also been misdiagnosed with herniated discs, carpal tunnel and a pinched nerve in the neck; all nonexistent. Then there were 30 physical therapy sessions on my injured leg and 7 traction sessions on my back, at which my neurosurgeon laughed. I am reminded of snake oil salesman of another era.

This endless journey has delivered poor results at great physical, emotional and financial costs. I am convinced that fee-for-service and doctors’ defensive medical practices must be addressed in reform, along with medical malpractice. We can learn a great deal by looking at the national health care systems of many leading industrial nations, particularly how they pay doctors and why medical malpractice is a non-issue. These nations provide better health at half the cost.

Meanwhile, I continue to search for answers while my patience, resolve and check book wear thin. In the mean time, last week I saw the neurosurgeon again and after stating my back was not in pain for the third time, he announced that no back surgery was warranted.

He finally heard me. Yet, I am walking with a cane.

Pearl Korn is an advocate of improved Medicare for All, the United States National Health Care Act (H.R. 676).

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  • R Watkins

    The fact that you thought an orthopedist should be available at all times in the ER and for someone else to pay for your cab fare indicates that your expectations of what the health care system can deliver may never be met.

  • rezmed09

    This is problematic on many levels. I believe you feel abused by the system and have been hurting but… We are presented with a case with limited information and asked to agree that the care was substandard based on providers: not being a specialist, or being a specialist but too busy – or too specialized, you did not get an MRI soon enough and then a provider ordered too many MRI’s. and you were not given full consent of risks and benefits of steroids. This leads to some questions:

    How is your knee now? Do you need surgery? Are you a candidate for surgery? Do you want knee surgery?

    If you don’t have back pain and don’t want back surgery, and if you had just knee pain why did you go for MRI’s of your back?

    In short, what do you want? – answers or surgeries or just evidence based care ? If you were a Canadian you probably would feel the same and would not have had nearly as many tests, bills and poking. But you would not have as many answers. The US system will remain broken as long as it is profit or acute care driven.

  • Vox Rusticus

    Hard to see where all this goes. Does the writer want specialists on call all the time and no EM doctors evaluating her in the emergency room? Or does the writer want MRIs right away, through the ER? Does she want only tests that eventually result in positive findings? And exactly what sort of systems does she want (this supporter of “Medicare for all”) that will result in her getting the kind of treatment other than doctors working for fees? Does she want to see only doctors working for a fixed salary? Only doctors who refer to specialists not affiliated with the hospitals or centers where they work, people with whom they may have less not more familiarity and knowledge of their capabilities?

    I really don’t see how this train of experiences, unsatisfactory as it evidently was in resolving the initial knee complaint makes the case for or against anything.

  • Abalone

    Providing Medicare, a fee-for-service program, to everyone is an odd way to “end fee for service medicine.”

    • Pearl Korn

      What I propose is Improved Medicare For All.The insurers must be removed along with fee for service. Those nations with National Health Care that retain insurers operate on a non profit basis. A combination of the public and private. Thirty percent of every health care dollar in the USA is spent on administration, paper pushing , advertising and profit by the insurance industry. While Medicare costs 3% to administer.

  • Surgeon

    Sounds like you want physicians to become postal workers. Be careful what you wish for.

  • ninguem

    French physicians are fee-for-service, as is much of the Continent. Some people, you can’t figure out what it is they want.

    • Pearl Korn

      French doctors are salaried and quite happy with the system. They use a non profit system of insurance delivery. The United States Health Care Act (H.R.676) is an IMPROVED AND EXPANDED MEDICARE bill, with 89 members of congress who support it. Doctors would once again be able to deliver the kind of care that brought them into medicine in the first place, without checking the clock .It would become patient centered.
      The passage of this bill would provide better health care at lower costs. Our nation could save $400 billion per year going to this system, while providing over 2 million jobs.

  • Jenga

    She’s seen one ER doc, three orthopods, one physiatrist, three neurologists and a neurosurgeon and it’s the physicians fault. Methinks her problem may not be medical.

  • Lucy

    I have had similar experiences with the health care system. Doctors too busy to really look at a problem carefully. No continuity of care. Doctors who feel it is your fault that they can’t cure you in 10 minutes. Doctors who don’t really care about you.

    In my community, we have wonderful postal workers. Most professionals are salaried. Are you saying that doctors aren’t responsible?

  • skeptikus

    Trial lawyers don’t get paid unless they win. Accountants routinely cover representation before the IRS if taxes get audited. Refractive surgeons often give guarantees and warranties . . . .

    Why don’t we adopt this model wholesale. Doctors don’t get paid unless they achieve what they say they’ll do. That’s accountability and that’s economic efficiency.

    • Vox Rusticus

      No problem with that, as long as I am allowed to charge whatever I see fit, and not have any form of caps from any third party entity, including the government. No limits. And I get to decide how the warranty is serviced, just like any other warrantor.

      “Warranties” are nothing more than bundled insurance policies, Their costs are wrapped in the prices for the warrantied goods we buy. And most warranties are capped at either return of goods for price paid or replacement at the discretion of the manufacturer, not endless services or repair for the life of the product.

      At present, most surgical services come with a de facto 90-day warranty. Most re-operations in that period are “ncluded” in the payment for the initial procedure (or are denied as such, whether they really should be or not.) Extending that period imposes extra liabilities, which have costs that must be paid. That is a job for underwriters. But they must be paid for.

      I, for one, will not take that on without being paid for the costs. Voters can vote for whatever they want, but you don’t get to have free labor for the price of your vote.

    • Pearl Korn

      Your second paragraph stating “doctors don’t get paid unless they achieve what they say they’ll do”. Nice idea, except I have never heard a doctor make a promise or guarantee about an out come,especially where surgery is involved. A warranty like on a clock or t.v. for 90 days is a nice idea.
      I am all for ACCOUNTABILITY.

  • skeptikus

    Agreed. Warranties would come with differential pricing. This would have to come with consumers in fact paying for their care. But, again, this is good. People with better health would get cheaper warranties. (The opposite of insurance . . . )

    Doctors should assume the role of underwriters to the extent possible. They are the best ones to calculate risk . . .

  • rezmed09

    I don’t think it is all black and white.

    Canadian docs are not treated like postal workers. From what I understand, they are paid based on their patient load – bit salaried. Right now they are well compensated. PCP’s are making more than their US counterparts and seem to be happier. Primary care is not dying in Canada as it is in the USA. Specialists in the USA might not like that system – and they are the majority of the US docs.

    • Vox Rusticus

      Honestly, I wouldn’t mind the Canadian system at all. The specialists in my field are busy, seem adequately compensated, have nice offices, plenty of vacation time.
      Where can I sign up?

      Sell Canadian-style taxes to Americans. Remove the sacred cow of mortgage interest deductions. Bring on the VAT or GTA or whatever they call it now. Bring on Canadian gasoline prices. Subsidize university study the way the Canadians do and give me the same retirement and medical coverage, and a judicial system that is free of buccaneering lawyers. You can’t do the Canadian medical care system without all the rest, sorry to say.

    • Pearl Korn

      You got that right.
      The Canadian system was modeled on our Medicare and is called Medicare.It is similar to the system that H.R.676 would create here. When there have been difficulties with the Canadian system it is because it has been underfunded. Yet, if you ask Canadians if they would want to opt out of their system the answer is a resounding NO.We must do a better job of educating docs on what could be.

  • http://www.ohiosurgery.blogspot.com buckeye surgeon

    What is it that you wanted done differently? No one put a gun to your head to go see all these specialists. Were you having pain or symptoms? Or were you just bored and felt like taking a jaunt to the local neurologist/neurosurgeon/orthopedist? I don’t get it.

  • jenga

    If the problem is nine physicians you’ve seen, maybe you would be better off without one. Alot of us didn’t sign up to be government employees, which is what medicare for all does. I won’t participate in such a system. One third of physicians are over 55 and a whole lot of them won’t either, which means next time you go to an ER with an orthopedic complaint this doctor won’t be on call.