The tension between physicians and health policy experts

The tension between physicians and health policy expertsThere’s an underlying tension between physicians and health policy experts.

Health policy experts take subtle jibes against physicians in their analyses, with many feeling American doctors are overpaid, which exacerbates health costs.  They tend to be politically progressive, and generally dismiss the issues that most doctors care deeply about.  Medical malpractice, tort reform and the cost of medical education, for instance.

And doctors can be antagonistic to policy experts.  As most wonks are not physicians themselves, doctors generally discount their opinions, since they haven’t gone through the rigors of physician training, and are shielded from the day to day realities of practicing medicine.

Yes, I’m generalizing, but those are the themes I’ve observed from the health reform conversation over the past few years.

But if we are to fix our health system, both sides need to come together.

Consider a recent NEJM piece, which asks the following:

Are U.S. physicians sufficiently visionary, public-minded, and well led to respond to this national fiscal and ethical imperative? It’s a $640 billion question.

Merrill Goozner, a progressive policy commentator, answers:

The short answer, of course, is no. If they were public spirited, would they lobbying as hard as they are to restore physician pay — the so-called “doc fix” — which will cost the government another $300 billion for Medicare over the next decade?

It’s a subtle physician-antagonistic response that policy wonks on the progressive side — Goozner, Ezra Klein, Maggie Mahar, and Paul Krugman, to name a few — occasionally make that only exacerbates the discord.

Yet, to successfully reform our health system, doctors need to be at the forefront, not policy experts.  And I’m not saying that because I’m a physician myself.  The data says so.

A Gallup poll, conducted in 2009,  found that physicians garnered the highest level of public trust when it came to health reform.

The tension between physicians and health policy experts

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Patients still trust their doctors. Which is why it baffles me when policy experts don’t give doctors many olive branches when making their health reform arguments.  Given the rancor surrounding the debate, it seems that reformers could use all the support they can get.

Take the contentious issue of physician salaries, for instance.  Most progressive wonks feel that American doctors are overpaid, and in their ideal world, would like a single payer system where doctors are on a salary in line with the rest of the world.  Ezra Klein, for instance, continually points to France to illustrate this point.

Well, it’s no surprise that doctors are hostile to that worldview.  Of course, no one likes to get their pay cut.  But, why not balance the argument by including the cost of American medical education?  Yes, American doctors are paid more than any other physician in the world.  But look at what it costs to train them:

The tension between physicians and health policy experts

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If policy experts included medical education reform (or medical malpractice reform) with their arguments for paying doctors less, it would be better accepted by the medical community.  I’ve written before that more than a few doctors would exchange medical school debt relief in exchange for a strict salary.  Or medical malpractice reform in exchange for less pay.

I appreciate the data-driven arguments that policy wonks present to illustrate, and potentially solve, our dysfunctional health system.  But charts by themselves cannot convince the public, whose acceptance is key to any variation of health reform.

To do so, health reformers need doctors on their side.  Why policy experts don’t make more of an effort to sway more doctors is a mystery to me, and a tragically missed opportunity.

Kevin Pho is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitter, and LinkedIn.

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  • http://med-path.blogspot.com/ thunderroad

    Health care is in a state of fiscal crisis. The industry also faces an alarming professional labor problem. Raising risk to physicians or lowering reward will exacerbate the doc shortage. This is a well thought out and well supported argument. Dialogue is key to finding solutions.

  • http://www.drmartinyoung.com Martin Young

    Well said, Kevin!!

    It’s a global issue. Where I practice in South Africa insurers claim as much of the medical pie as all consulting doctors in all fields combined, to ‘administer’ their funds – presumably a much easier task than being available day and night to sick people with infinite variables of disease.

    Yet doctors alone are seen as being too expensive. Yet try suggesting a policy expert (or insurer executive) earn the same income for the same liability and inconvenience – oh. no, completely unacceptable, exploitation!!

  • Joe

    Why are policy wonks not-so-subtly antagonistic towards physicians? Why are tired, one-sided arguments made instead of a reasoned, thorough explanations? The survivors of the journalism decline need to earn their keep any way possible, and controversy means mouse clicks means advertising money. The only policy wonks worth reading are not writers or bloggers but those who hold real-world positions and just happen to occassionally write on the topic, ex. Uwe Reinhardt.

  • http://www.drdarrellwhite.com drdarrellwhite

    The other important point with regard to Physician pay is the amount of income that medical students and physicians in training forego before they are actually full members of the practicing physician workforce. This group of individuals is generally at the top of the grade curve, interviews well, and is obviously motivated and driven. Where would they end up if they did NOT go to medical school? What kinds of jobs at what kinds of salaries would attract them were they to turn their backs on medicine as a career.

    I graduated from college in 1982. Most of my classmates went directly to work, and those who occupied the same rank strata as those of us who went to medical school typically made 6 figure incomes within a few years of graduation. The difference isn’t non-med student salary minus zero, but non-med student salary plus the NEGATIVE sum of med school tuition and expenses. Big number. Even the paltry resident salaries fail to dent this difference.

    Physician salaries that are perceived to be so high never really catch up to the income earned by those who physicians would deem academic peers, another reason why the argument that physician pay is a strawman argument used in order to manipulate the audiences of the policy “experts”.

    I’m pretty sure I’ve never heard any physician of any ilk ever say the words: “I’m overpaid”. When we read the salaries of various non-physican players in our world, or those of folks like Krugman who provide little to no real value to a patient, that’s not very surprising, is it?

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    Whether physicians are, or are not, overpaid is largely irrelevant, considering that physician income is a small fraction of health care expenditures. What probably bothers the experts is that individual physicians have too much control over the system. Just imagine hundreds of thousands of folks doing whatever they want to do, with nobody able to regulate from the top. This is why you hear words like “fragmented” in most expert opinions. This is why “fee-for-service” is considered evil. This is why the “cottage industry” has to die. There is no other industry of this magnitude where regulators, corporate or government, have so little power over individual workers. I guess the way physicians choose to practice medicine, and the fact that the industrial revolution largely bypassed medicine, offends some people’s sense of order.

    • imdoc

      I am trying to understand this. You are stating that individual doctors, largely disconnected from each other and in competition with each other in a cottage industry, are somehow exerting excess control? How is that possible?
      Are you concluding that the population at large is much better served by some small committee to make all of our health policy decisions?

      “Just imagine hundreds of thousands of folks doing whatever they want to do, with nobody able to regulate from the top”
      Which doctors are working in isolation of regulations? Licensing is just the beginning

      • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

        We have a disconnect here. I was just trying to explain what I think the experts are driving at. I completely disagree with the premise and as Patrick suggests below, I may have phrased ambiguously.
        The cottage industry does not lend it self to being controlled from the top easily. Experts usually want to exercise such control. Short of transforming to the NHS model, the solution seems to be to aggregate doctors in corporations where they become just employees, and employees are really easy to control, particularly if they all work for very large corporate entities.
        I do believe that the regulation and uniformity of service that needs to be imposed, according to same experts, far exceeds licensing and such.
        And I am concluding that the population at large is much better served by independent physicians scattered all over the spectrum, but in the name of legendary efficiencies, the train is moving in the opposite direction.

        • ninguem

          The type of healthcare system contemplated under “Obamacare” would make the NHS look good by comparison.

    • buzzkillersmith

      You’re right. For the wonks it’s mainly about control.

    • Patrick Mac

      Margalit you state “What probably bothers the experts is that individual physicians have too much control over the system.” I would rephrase your statement as “Many of the pundits and policymakers feel that physicians have too much control over the system”, unless you are in agreement that physicians have too much control.

      How ironic that last year the the UKs National Health Service decided that the governmental top-down control of health care was not working and proposed to give more control back to the primary care physicians. From:http://www.publicservice.co.uk/news_story.asp?id=13016
      “• We will stop the top-down reorganisations of the NHS that have got in the way of patient care. We are committed to reducing duplication and the resources spent on administration, and diverting these resources back to front-line care.
      • We will cut the cost of NHS administration by a third and transfer resources to support doctors and nurses on the front line.
      • We will strengthen the power of GPs as patients’ expert guides through the health system by enabling them to commission care on their behalf.”

      The policy wonks and bureaucrats want control. The fatal conceit is that they “know” they can correct the problems if they can gain control over the system and the actions of physicians. What they don’t know is what they don’t know. They do not appreciate the complexities of human disease and the need for decision making at the bedside and in the exam room, tailored for each individual patient. People are not widgets and treating them as such is not the answer. I would much rather have primary care physicians in charge of rationing care than some distant bureaucrats that do not have a clue about individual patient needs.

  • http://drsamgirgis.com Dr Sam Girgis

    Health care policy needs to be made by health care providers… i.e. Doctors and Nurses! We need to be sending more of our professionals into management roles. As for physicians salaries being too high… I am an internist working as a hospitalist and consider myselft to be part of the working middle class, struggling to pay back my student loans and my mortgage.

    The truth of this situation needs to come to light.

    Dr Sam Girgis
    http://drsamgirgis.com

  • http://www.prleap.com/pr/150153/ Dr Kelly Sennholz

    This is a fantastic post. Health care policy is being made without the input of many physicians which is a huge mistake. Not only should medical school be free or in exchange for service, but leadership skills should be taught in every medical school.

    Physicians are taught how to be wonderful doctors but when they get out of training, the realities of real world business hit them in the face. With fantastic, caring, competent primary care doctors going bankrupt because they worked 80 hours a week taking care of their patients but were not able to make the numbers work for themselves is a huge shame on our country.

    There are many fantastic ideas for reform coming from doctors, but who is listening? Right now, just an echo chamber.

    Great post, Kevin!!

    • http://drpauldorio.com Paul Dorio

      Here here! I agree wholeheartedly.

  • Tim Martin, MD

    This is a great conversation! And it still misses the point that only doctors are able to perceive. Here’s the point – It’s all about each individual patient! Are we fragmented? It’s because I see 25 INDIVIDUALS each day, not some monolithic collection of diseases and medications which always does what it’s told. Are we leading? I undertake to lead 25 individuals through the complexity of the local hospital system, employer demands, insurance restrictions, communications barriers every day. Are we over paid? Most of what I do each day I couldn’t possibly collect a penny on, let alone place a pricetag on. How do you charge for peace of mind or reassurance?

    There is no other industry like healthcare. We have to let our government and policy makers know that in this realm, statistics never tell an accurate story and trying to fit doctors and patients into a limited number of cubbyholes will only result in missed diagnoses and opportunities.

  • Kristin

    I’m just curious, can you point me to some of Maggie Mahar’s articles on this? I read her book a while back and I’d like to have some concrete examples of the arguments in question.

  • Ed

    I think the problem is more general. Health IT often does not include Docs and Nurses. Hospital administrators often treat clinicians with disdain and Boards reward them (and themselves) richly. Health research is done by non-practicing MDs or PhDs who have little motivation to do anything but suggest more research! The administrative empires of research administration are bigger by the year.

    Money is being spent in so many unproductive ways in “healthcare” since it is a feeding trough for so many who dont provide or receive treatment.

    • pj

      Well, at least we Docs can “boycott” some of the more wasteful research. We should call out editors who include research in their journals that contributes little to real world medicine.

  • http://www.residencynotes.com txmed

    I interviewed Mathew over at The Health Care Blog once for Medscape and he basically said physicians were too close to the issue and should just butt out and leave the entire debate to policy wonks.

    I think antagonism from physicians is understandable for the reasons Kevin puts forward in his post. But why it sometimes seems the policy experts are adverse to physician participation in the process, I’m not so sure. It seems counter intuitive as Kevin points out.

    And I agree whole heartedly there certainly is room for physicians and other participants in the process to work in terms of reimbursement reform.

    I would certainly trade a huge chunk of my future earnings, especially as a resident in a highly compensated specialty field, in exchange for early loan repayment. Indeed, its hard to imagine significant reimbursement reform having any real success without concomitant reform of the funding sources for medical education. Medical education is going to have be massively more subsidized.

  • buzzkillersmith

    I don’t much care what the wonks say, but a financial freight train is coming down the tracks in our direction. We are simply not going to be able to continue to do things in medicine as we have done them in the past. Medicine is a victim of its own success.

    • Primary Care Internist

      as the financial freight train gets closer to the edge of the cliff, the policy wonks will accelerate their attempted redirection of the problem toward “bloated” physican incomes, and try to deflect attention from the billions of dollars wasted on administrative fees & salaries, pharma and insurance profits for shareholders, and billion dollar salary & bonus packages for execs. Not to mention hospital administrators like michelle obama who pulled in more than DOUBLE what most doctors make, and tort reform? don’t even get me started,..

      • stitch

        Bingo. Let’s also not forget medical devices. Why does a drug eluting stent carry a price tag of $30K, for example? Is anyone doing anything to reduce those costs? No, we’re going to reduce the payment to the doc who takes the risk of implanting the stent while the stent rep may make more than the doc. It’s an absurdly screwed up system.

  • http://healthasahumanright.wordpress.com Health as a Human Right

    An interesting discussion indeed. As a health policy attorney, I would disagree with many of your arguments.

    I don’t actually think that most in policy believe doctors are paid too much. It’s not even the crux of the argument when it comes to payment reform. Doctors are targeted because they are easy to target, as I see it. Doctors are disjointed from each other and unfortunately, though they should advocate for themselves, most don’t.

    In recent reform measures, I actually find quite few practitioners actually know what’s going on. Talk about accountable care organizations, health information technology, patient centered medical homes and they look confused. Unfortunately, they aren’t involved. Which in a way is a good thing – they’re focused on their patients (as they well should be). But this means not knowing the laws that affect them.

    AMA is a good lobby organization and each part of your profession has their own lobby organization to fight for them – so it’s not individual doctors vs policy makers. In fact, these lobbyists do a damn fine job for you and weild a lot of influence in the policy world. If you don’t like what they are doing, talk to them, get involved, speak out.

    Also concerning is that your idea of policy is focused on the cost of medical education, med mal and tort reform…. Those aren’t the only policy issues – though I recognize that you likely feel their impact the most. I understand that medical education is expensive – so is being an attorney. Attorney’s have it far worse honestly. Starting salaries are $45,000 for most, if you can find a job. Debt can be just as much. So don’t pity yourselves in this regard. We all have a tough rap when paying for advanced degrees. Working in the non-profit field, going from grant to grant and finding work where I can, I have yet to make above the federal poverty limit since graduation and have no way to pay my loans. There are no options for lawyers – but many doctors can find debt relief in their states by working in under-served areas.

    Some of us get that you are underpaid for the work you do. The overload of patients to make ends meet in your practices on top of the administrative burdens you face and some policy makers want to keep piling on you. There are some of us, more than you recognize by reading popular blogs, that try to fight for you in that respect.

    Med mal and tort reform are different. I might be one of the few who gets that tort reform as proposed and in place isn’t really that good for anyone. But move beyond these issues to the wider policy discussions about the system as a whole – not these remnants of poor policy developed ages ago in misunderstanding that it’s a bigger problem than doctors’ behavior. In focusing on this aspect of policy (which is usually the only aspect of policy people understand when I say health policy) will not solve anything.

    So policy experts on your side you say. That is just as cruel a jibe as you describe as directed toward your profession. Not all policy experts are against you. We may not have physician training but we have experience and knowledge that you cannot attend to when doing your jobs. It’s a 2-way street – you have to be in on the discussion as we have to seek out your opinions. It’s a missed opportunity on your part to not understand the issues and contribute to the discussion.

    I sympathize with you that policy imposed on doctors, and really any profession, isn’t the way it’s supposed to be. But some of us are advocating for you and trying to make the health care system an actual working system so that you can be doctors. It’s mean to vilify all policy experts.

    I take great offense to this post as a policy expert. I’m sorry you think so poorly of us.

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    “..trying to make the health care system an actual working system so that you can be doctors”

    I think that pretty much sums up the incredible presumptions common amongst policy wonks – the idea that policy folks know best what doctors need in order to be doctors, whatever that means.
    It sorts of reminds me of the way women were treated not too long ago: “don’t worry your pretty little head with these complicated manly business, we’ll take care of everything for you sweetie, so you can have all the time in the world to do all those things you enjoy…. we just want you to be happy hon” – and in the process turn you into a dependent, helpless creature that does exactly what we want you to do, or starve.

  • http://healthasahumanright.wordpress.com Health as a Human Right

    Your comments on policy makers paint us to be patronizing of you, that you are not competent enough to contribute to health policy discussions. I am sorry you would imply that from my words. As the rest of the post suggests, doctors and health care providers are ENCOURAGED to enter the discussion but they DON’T!

    Nor did I say that I know better than doctors. I said that most doctors I’ve encountered do not know anything about policy and are not involved. So in that respect, I may know some more – not about the practice of medicine but about the changes proposed to the practice of medicine.

    Some of us actually do listen to you. We ask you how you feel about policy ideas and then take that forward. We try to do what is in your best interests – but you actually have to tell us what those are by getting involved.

    I certainly do not believe you are inept. You likewise cannot assume we are inept. Are you telling me that you don’t want us on your side to make the health care system better?

  • http://www.healthbeatblog.org maggiemahar

    Kevin–

    First, I often have written that we should subsidize med school education so that doctors don’t graduate with thousands in loans.

    Median income for a primary care doctor is now $175,000.
    In the past, I have suggested that if medical education was (entirely) subsidized, more physicians would be willilng to go into primary care. But some physicians reply that primary care still wouldn’t be attractive because family physicians make so much less than proceduralists.. And proceduralists make so much less than CEOs. . . .

    \When it comes to malpractice and tort reform, the comments on my blog again suggest that physicians do not all think alike. Sojme believe that we need to cap awards. Others say “No,” what we need are special courts and arbitration panels instead of jury trials.

    Still others say that what we need is less malpractice — fewer errors, greater use of checklists,, etc., more emphasis on patient safety. Some believe that full diclosure and saying “I’m sorry” works; others don’t. (I personally favor “Sorry” and full disclosure followed by special courts if sorry doesn’t work.)

    There are many patient-centered professionals out there we truly do put the patient’s interests ahead of their own interests, and I agree that these doctors .should be in the vanguard of reform.

    . Only they can convince patients that “more care” isn’t necessarily “better care.” As you say, patients trust them. But when some (usualy conservative) physicians put malpractice reform and their own income at the top of the reform agenda, they seem less than patient-centered. .

    • stitch

      NPR had a piece today on the single-payer law being signed into law in Vermont. The physician being interviewed said yes, there was some physician opposition, mostly among subspecialists, but overall physicians were in favor of the law by a 2:1 margin. Kinda belies that “usually conservative” thing, perhaps?

  • http://preventioninstitute.org Prevention Institute

    Thanks for your post, Kevin! We agree that health care reform and other policies that support health cannot be successful without leadership from physicians. As you point out, the public looks to physicians as trusted sources of information on health matters. I just want to add that the public health world has indeed caught on to this, and efforts are being made to join forces. Prevention Institute has released a textbook (Prevention is Primary: Strategies for Community Well-Being: http://tinyurl.com/2e9fndl) on community health strategies written by experts ranging from physicians to professors to community organizers. We also recently released a paper on Community-Centered Health Homes (http://tinyurl.com/3uwrjol), which outlines how community health centers can incorporate prevention while delivering high-quality medical care. We need to bridge the false dichotomy between public health and medical care and work toward our shared goal of supporting healthier lives for all Americans.

  • http://www.drdarrellwhite.com drdarrellwhite

    Ah…Maggie Mahar wades in with a post which is actually quite reasonable, pointing out the inconsitencies and contradictions among and between the vaslty diverse universe of physicians, and how hard it is for anyone, much less a kind-hearted, well-meaning healthcare policy expert to divine a consensus. Nice points, all.

    Sigh…but then, she just can’t help herself. ” But when some (usualy conservative) physicians put malpractice reform and their own income at the top of the reform agenda, they seem less than patient-centered.” Where to start…where to start…

    How does one know what the political/philosophical bent is of the physician who puts med-mal reform at the top of his/her list? Adding the word “conservative” here is a subtle and elegant attempt to prejudice a reader against those who would champion malpractice reform for whatever reason. Political label as perjorative. Well-played, Maggie, but it’s a strawman and you know it.

    How do we not know that those physicians who champion malpractice reform are not simply prioritizing their efforts, perhaps participating in that part of the conversation that is most meaningful to them? How in the world can one make ANY assumption about the manner in which they practice by noting the fact that they feel that malpractice reform is a priority for whatever reason (decreased spending on defensive medicine; enhanced doctor-patient interactions by removing the risk of frivolous suits generated by poor outcomes in the absence of mal-occurrance, never mind malpractice, etc.)? Again, a subtle and elegant smear, but knowledge and advocacy of an issue does not in any way equate to any particular philosophical bent with regard to the practice of patient-centered medicine.

    And finally, we must come to the thinly veiled critique of physicians who are concerned about their incomes, an example of what Kevin wrote in his post: “Median income for a primary care doctor is now $175,000.” That’s a lot of money, eh? Where/what’s the beef? Hmmm…but what, pray tell, is the MEAN income of primary care doctors? The MODE? It’s not $175K. Again, very nice writing and very nice positioning, but we couldn’t ask for a better example of the disconnect between physicians and heatlhcare policy “experts” than Maggie Mahar’s post, even if we catch the “pay medical school tuition” bone.

    • Alex

      Relax Dr. White. Maggie used small-c conservative and did not put Republican. She is referring to the fact that most physicians are lean conservative, whether that be independent, Blue-Dog Democrat in areas, Republican, libertarian in some aspects, etc.

      • Joe

        It is that parsing of words that is so frustrating Alex. If you want to understand Maggie’s point of view, they are evident in her comments here and elsewhere.

        Believe it or not, doctors are generally very smart. It is pretty hard to pull one over on us if we care about the topic. It is disrespectful to try to fool us or parse words to try to win an argument. I have seen wonk bloggers bait their commenters and then call the commenter the problem when it is pretty obvious the wonk blogger is funded by a group with an agenda.

  • Patrick Mac

    Maggie,

    I know your statement that physicians have different ideas about tort reform, doesn’t mean we should not seek it. Please correct me if I am wrong. I am confused, particularly with the post on your blog earlier this year entitled “Instead of tort reform, why not focus on reducing actual malpractice?” This post, like many others on your blog, create the very tension that Kevin’s post here is speaking of.

    Look at how those other countries deal with medical malpractice. You know the ones that spend significantly less on health care than we do. I doubt you will find many malpractice lawyers there that earn nearly 27 million dollars in a single year, suing doctors, like John Edwards did in 1995 (http://www.thinkinglike.com/S-Corporation/John-Edwards-Saved-With-S-Corporation.html). We need to put our politician’s feet to the fire over this one. The trial lawyer lobbying influence here is palpable. One year, one lawyer, $26,900,000 that could have provided health care to thousands of patients. Politicians and pundits like you could ingratiate yourselves to physicians if you would support and legislate significant tort reform measures.

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    Isn’t tort reform a State issue? Why would we want the Federal Government to get involved, and why aren’t the Republican States enacting tort reform? Or is this a “bi-partisan” preference to favor lawyers?

  • Joe

    I for one have found disdain for any differing opinions on health policy blogs. Deletion of posts is typical as is editing and veiled superiority complexes are not well hidden. Many of these same bloggers are employed by organizations with an agenda, right and left. Dirty trick politics has no place in medicine, it certainly can’t help.

  • http://www.curinghealthcare.blogspot.com Stephen Beller

    In discussions like this, I’ve found it best to start by focusing on what I think everyone would agree is the ultimate goal: We must reduce overall healthcare costs and improve quality, which would increase value to consumers (patients/clients), improve their quality of life, and increase access.

    The metric for Value is Quality divided by overall Cost. Quality is the effectiveness of (a) treating illness/dysfunction treatment (as measured by risk-adjusted clinical outcomes, such as changes in a patient’s signs and symptoms); (b) preventing illness/dysfunction (wellness); and (c) stabilizing chronic conditions (disease management). Overall costs—including the cost of meds, tests, treatments and equipment/devices—rises because of inefficiency, waste, errors/malfunction resulting in additional care, excessive tests and procedures, over-prescribing, excessive risk, failure to select good lower cost alternatives, administrative & operational overhead (including malpractice insurance), etc. From a consumer’s perspective, therefore, greater value care is more cost-effective care.

    I contend that we should all be focusing how to increase healthcare value by:

    (a) Rewarding providers and manufacturers who deliver higher-value services and products

    (b) Enabling physicians and other practitioners to deliver high-value care through health IT, care coordination, ongoing clinician-researcher collaboration to build and evolve value-enhancing evidence-based guidelines, etc.

    (c) Enabling consumers to distinguish between high- and low-value services and products

    (d) Reducing providers’ economic burdens by lowering medical school costs through subsidies and malpractice insurance rates for high-value providers.

    This is the essence of a “Value-Pricing” (Pay for Value) model of healthcare; it is a sensible alternative to the insane open-ended fee-for-service (pay for volume) model and the restrictive salary-only model.

    The policy wonks, healthcare providers, researchers, payers and consumers ought to be debating how to make Value-Pricing a reality since it is the only rational way to achieve the ultimate goal presented above. All other conversations simply miss the point!

  • http://onhealthtech.blogspot.com/ Margalit Gur-Arie

    Very well put Dr. Beller, but I think the conversations will continue to proliferate precisely because, as you say, Value = Quality/Cost.
    However, Quality and Cost are not independent of each other. Generally speaking, starting from zero, Quality increases with Cost. We are intuitively assuming that at some particular point on the graph, Quality will either stay flat or begin decreasing with increased Cost.
    The problem is that nobody knows where that point is and the bigger problem is that the aggregate population Value graph is completely different than the multiple individualized Value graphs. On top of that, both Quality and Cost are composite values with unclear internal interdependencies within each and across both. For example, since you mentioned IT, technology definitely increases Cost and mostly Quality too, but in some instances technology will decrease Quality.
    It is this uncertainty and ambivalence that worries folks and creates all sorts of fears and concerns, which in turn create heated discussions on this or that particular element of the equation.

    • http://www.curinghealthcare.blogspot.com Stephen Beller

      Thanks for you comment, Margalit. Yes, Quality and Cost are certainly related/interdependent, but that isn’t the main problem, imo. I submit that the “FUD factor” (fear, uncertainty & doubt) keeping dead-end dialogue going is a result of ignorance, i.e., we know very little about the most cost-effective ways to prevent, diagnose and treat particular conditions for particular patients in particular circumstances. I call this ignorance the “knowledge gap” (http://wellness.wikispaces.com/The+Knowledge+Gap). Furthermore, there’s been little economic incentive to gain that knowledge.

      That’s why we ought to be focusing on gaining and using personalized evidence-based knowledge (and related tools) to guide clinical decisions. After all, if everyone received the care they needed and nothing more, and if that care was delivered competently and efficiently across the board, and if providers and manufacturers delivering high-value services/products received greater income/revenue – then it’s only logical to conclude that there’d be much less FUD, overall quality would improve, individuals and populations would be healthier and more productive, and overall costs would drop.

      Yes, there would have to be lines drawn where improvements in quality are not considered cost-effective (high value) because their potential benefits are outweighed by the cost. Nevertheless, in a capitalistic society like ours, we don’t prevent people from paying out-of-pocket for such “overly expensive” care if they really want it.

      Unfortunately, we’re a long way from generating the knowledge we need to make decisions based on cost-effectiveness research, and such research takes time and money. But the longer we wait, the worse things are becoming. I contend, therefore, that our country (and the world) should focus primarily on developing and implementing inexpensive strategies for gaining and using the knowledge and tools we need to implement the value-pricing model.

  • http://www.healthbeatblog.org maggiemahar

    Dr. Darrell–
    First, On primary care doctors’ incomes: As I am sure you know, when I say that median income is $175,000 that means half of these docs earn more and half earn less.
    When you look at a “mean” rather than a median average, it tends to be higher because relatively few people at the top pull up the average. ( This also is true with primary care docs incomes.– see numbers below)
    Here is a break-down as of 2011 (from Medscape’s 2011 report):http://www.medscape.com/features/slideshow/compensation/2011/internalmedicine#
    Surprisingly, roughly 9% of primary care docs earned between $300,000 and $500,000+
    About 7% earned $250,000 to $299,000
    About 17% earned $200,000 to $250,000
    About 15% earn $175,000 to $199,000
    Another 15% earn between $150 and $175,000
    So about 63% earn more than $150,000 with about one-third earning somewhere between $200,000 and $500,000. (This is the group that would pull up the mean average. I assume the high earners have a concierge practice, or have a loyal following in places like Manhattan, L.A. Miami and very likely don’t take insurance. )

    Is $200,000 enough for an individual to live comfortably? Money is relative. For most people it all depends on how much your friends and neighbors have. Though it’s worth noting that individuas who earn over $200,000 are in the top 2% top on the income ladder, earning more than 98% of all Americans. Couples earnign $250,000 are in the top 2% of couples.
    Roughly 37% of primary care physicans earn less than $150,000.. AT the low end, they work part time (see below)..
    About 13%-% earn between $125,000 and $150,000
    Roughly 8% earn between $100,000 and $125,000
    And 17%- earn $100,000 or less. (MOST OF THESE WORK PART-TIME says Medscape.)

    Medscape explains: ” Internists’ income by and large is within the range of $125,000 to $299,999, with a plurality earning from $150,000 to $249,999. Just under 10% of internists earned $300,000 or more. A significant percentage (17%), mostly those working part time, earned under $100,000. Although reimbursement rates remain low, the shortage of primary care physicians has boosted income, according to physician recruiting firm Merritt Hawkins, part of AMN Healthcare, in Irving, Texas)
    It’s also interesting to note that “Internist income varied throughout the United States. The Western region (California, Hawaii) showed the highest median income, at $188,000. By contrast, the Northeast (New York, Massachusetts, Connecticut, Rhode Island, New Hampshire, Vermont, Maine), showed the lowest median income, at $150,000″
    In the Northeast, most primary care docs work solo or in small groups. In the Northwest, California and the Upper Mid-west they are more likely to work in large multi-specialty organiations like Kaiser, Mayo, Cleveland Clinic, Peugot Sound, etc. It seems that when it comes to income, these doctors are doing better.
    ON TORT REFORM: I didn’t mean to poison the well by suggesting that “conservatives” favor tort reform.
    First of all, many conservativeds are proud of being conservative and do not see it as a pejorative term. I think of Michael Cannon, who I like (and have debated.)
    Secondly, it is a known fact that Republicans strongly advocate tort reform, and in recent years they have been our “conservative” political party. (Try Googling “tort reform” and Republicans and you’ll find dozens of articles about their support for the idea.)
    Conservatives are philosophically opposed to “plaintiff’s attorneys” suing doctors as well as corporations for supposed product defects, etc. They see “plaintif’s attornies” as “ambulance chasers” who drum up business fior themselves by bringing friviolous suits. When it comes to the plaintiff’s bar suing corporations, conservatives tend to see things from the point of view of the shareholder rather than for the point of view of the consumer.

    By contrast, liberals tend to see “plaintiff’s attronies” as lawyers protecting “the little guy.”
    Conservatrives and liberals also differ on which is more important: freedom or having an egalitarian society.,
    Conservatives tend to value freedom most highly, and this includes the right to earn as much as one can, conserve and preserve one’s wealth–without undue taxation–and pass it on to one’s heirs. (This is why conservative object to inheritance taxes
    And This is why more conservative physicians tend to be concerned about government reforms that would infringe on their incomes.)
    Liberals (or progressives) tend put an egalitarian society highly at the top of their list of goals– this means a society where the gaps between the working-class the middle-class and the upper-class are much narrower– usually because of higher taxes, and lower wages at the top.
    This is why liberals are more likely to favor universal coverage even if some reimbursements for some services (that the Affordable Care Act calls “overvalued services” are cut, while reimbursements for “undervalued services” are riaised. In general, this means that reimbursements for
    preventive care will be lifted while reimbursements for some expensive tests and treatments that offer questionalbe benefit to the patient will be trimmed.
    No one likes to see their income drop, but as one specialist/ reader wrote on my blog: “I earn $435,00 a year. If my income dropped to $400,000, I could live with that.” (I’m quoting from memory– he could have said $450,000 and $410,000–it was somewhere in that range.)

    Patrick– If you have read my posts on tort reform you know that:
    a) capping awards has not worked to reduce overtreatment in Texas and
    b) When PHYSICIANS at Harvard’s school of pubic healh reviewed malpractice cases, they determined that yfew were frivolous (in most cases patients were seriously injured–though this may not have been the doctor’s fault. ) Moreover, relatively few doctors account for the majority of lawsuits. (In most specialties, suits are relatively rare.) . Finally, in most cases where the doctor lost the case or settled, the physicians reviewing the cases said that the doctor had, indeed, committed malpractice.. .

    That said, I think we need a diffferent way to address malpractice claims– special courts where the judges know a great deal about medicine (not jury trials), arbitration panels and full discosure of what actually happened, , Hopsials & doctorws saying “we’re sorry” plus offering a settelment when appropriate. In Michigan they have adopted this approach, greatly reducing lawsuits and costs associated with lawsuits. People sue when they are stone-walled– when doctors and hospitals refuse to talk to them.
    99 percentof patients who are injured do NOt Sue. They understand that doctors are human, and that accidents happen. Most people want to trust their doctors.
    Finally, I think everyone– patients and doctors and nurses– agree that there are too many preventable errors in our hospitals. We need to improve hospital “systems.” Hospitals that have succeded in doing that find that the number of suits fall dramatically. .

    • Joe

      The bit about liberal lawyers being plaintiff’s lawyers and conservative lawyers being I guess the opposing corporate defense lawyers is absolutely precious … and revealing. Although I’m pretty sure there is no science behind the statement, it does show the liberal blogger’s belief system at work, if it fits the narrative it must be true.

      However, the point is obvious, it is the plaintiff’s lawyers who would lose out in tort reform and the liberals believe liberals are plaintiff’s lawyers.

      Also, could it be that instead of conservative pushing tort reform, the opposite is true, liberals resist tort reform.

      Absolutely precious how the belief system pervades the entire arguement without even a hint of self realization.

  • http://www.healthbeatblog.org maggiemahar

    Patrrick–

    Please see my response to your comment in the final section of my comment headlined “Dr. Darrell” above. . I meant to include you in the headline– my mistake

  • http://www.healthbeatblog.org maggiemahar

    Tony–

    I agree with virtually eveything you say.

    But when it comes to Non-Profit health care insurers, some do actually add value to the system.

    For instance, in northern California Kaiser Permanente has greatly reduced smoking by offer free somking cessation programs with free nicotine patches.

    Kaiser in N. Calif also has greatlly reduced mortaities due to heart disease.

    Other non-pfroits also have added value.

    And even Aetna (decidedly a for-profit) has added value by running an experiment which showed that if dying patients get hospice care they not only cost insurers less, but Live Longer (less anxiety, less pain) than if they remain in the hospital.

    As a result , Aetna is now paying for Hopice care without requiring that patients give up potentially life-saving medications and treatments. In other words patients don’t have to make the very hard decision that they are definitely dying. They can continue the treatments and go into hospice.

    At the same time, once thse go into hospice they tend to give up some very painful treatments . . of their own vollition– because they are less anxious
    .
    Meanwhile, patients and rellatives are much more satiisfied by their end-of-life treatment. Less agony, more acceptance of death when patients are allowed to die with dignity–making their own choices about what they want to happen to them. .
    Medicare, on the other hand, won’t pay for hospice care unless patients “give up” and refuse all potentially life-saving medications and treatment.
    Sometimes government program are jless flexible–just not as as willing to experiment and not as wise.
    This is why I think that, ideally, we should have a government health care plan competing with private insurers (mainly non-profits) rather than a “Single-payer” system.

  • http://www.healthbeatblog.org maggiemahar

    Tony–

    Under reform the poor will have access to hospice care through Medicaid. (States will no longer be able to refuse Medicaid to poor adults because they don’t have children.)

    You are right that, when compared to other countries,we rank poorly in terms of life expectancy, infant mortality, material mortality during childbrith–even if you only compare white Americans to white indiviiduals in other developed countries.

    But the major cause is Not lack of access to healhccare. When you analye premarture mortalities (preventable deaths) it turns out that lack of access to healthcare explains only 10% of these deaths. The major cause is poverty. See Dr. Steven Schoeder’s outstanding Shattuck lecture. I write about it here.http://takingnote.tcf.org/2011/05/when-poverty-and-unemployment-are-misdiagnosed.html
    In the U.S. we tolerate more poverty than other developed countries. A larger percentage of U.S. children lilve in poverty than in any other developed nation. And these are not immigrants (legal or illegal); these are native-born children.
    In other developed countries, people pay higiher taxes and provide more safety nets for low-income people–not just universal coverage, but better public education, housing etc. .

  • http://wellness.wikispaces.com Sabatini Monatesti

    Everyone has a piece of the elephant. However, we may not be using the same system model to describe the problems, high cost of service, and issues facing the delivery of “sick care” or access to valuable health care services. Today the USA citizen is dealing with (1) increased cost of unaffordable and elective service (e.g., readmission cost, hospital-acquired infections). In addition (2) this same citizen is unable to determine the quality of the service rendered, (3) not all citizens are treated equally, (4) nor are all patients in compliance, (5) nor do all areas of the country provide the same access to care. The “sick care” system (6) does ration services based on ability to pay, and yes, expensive charity (7) does exits at the ER. Dr. Beller is on the right track. We must define “sick care” value in terms of quality and cost. We must further define quality in terms of continuous improvement leading to an acceptable error tolerance level achieved at affordable cost. Hence, the “sick care” delivery workflows must include checks and red flags to indicate errors, omissions, readmissions, defects and failure to perform, with remediation included along with measurement and reporting. I believe that when a failure is uncovered, the “sick care” organization that injured an individual must fairly compensate that individual without hesitation. I further believe that we need to move forward quickly on “meaningful use” implementation and that the Community-based Transitions Program go into effect as soon as possible.

  • http://www.healthbeatblog.org maggiemahar

    Stephen Beller–

    Yes, higher quality and lower costs go hand -in-hand.
    Inefficient healthcare is costly. Errors are costly. And in both cases, patients suffer.

    I disagree with you on only one point:– that health care reform shoudl be able to “Enable consumers to distinguish between high- and low-value services and products.”

    As you know, measuring the quality of healthcare is extremely difficult. The average American just doesn’t have the skills or training to do this. Its not just that he or she hasn’t gone to med school; a great many Americans have not recieved an education that has taught them how to think analyticaly.

    In many situations (buying a car, for instance)
    basic common sense will stand you in good stead.

    But when you are told you have cancer, how does the average person sort out the pros and cons of various treatments?
    Shared-decision-making can help more patients understand comparisons between different treatments– but many still are not able to grapple with the complexity and ambiguities. (That said, I still think shared decisoin-making is good for virtually all patients because they have a chance to epxresss thier priorities–what is most impotant to them. “I don’t want ot be in pain.” or “I want to lilve as long as possible.” Or, “iI want to do everything i can to save my breast.” Or “I just want to get this over with– as quickly as possible–even if that means losing my breast”.) This is all very useful information for a doctor who is trying to practice “patient-centered” medicine.

    Finally, as you know, most of our health care dollars are spent when patients are suffering from serious chronic illnesses. Typically, they are older. Often, they are poor. Often they are frightened. Frequently they are in pain.
    These are not “consumers”. These are sick people. They are not in a position to act as “smart consumers”

    We just cannot shift the burden of reudcing health care costs to elderly, ill and dying patients.

    Doctors must lead refrom by making the decisions that will best protect patients

    See the article in the most recent NEJM on reducing the cost of cancer care– wirtten by two doctors. It is excellent.

    • http://www.curinghealthcare.blogspot.com Stephen Beller

      Maggie –

      I appreciate you excellent comments. I agree that there are daunting challenges to enabling consumers—as well as healthcare professionals—to distinguish between levels of care value because it is difficult to (a) measure quality in a meaningful way and (b) understand the measures in a way that guides rational decisions. I also agree with the benefits of shared decision-making, including seriously considering a patient’s preferences. I wrote about this issue four years ago while criticizing the then touted “consumer-directed” healthcare strategy in the guise of “personal responsibility” (see http://bit.ly/mS4FOm).

      Nevertheless, in taking a long-term view, one of the goals of healthcare reform should, imo, be creating processes that can translate evidence-based comparative- and cost-effectiveness research into easily digestible information that increased consumer’s knowledge and decision-making abilities, along with related “Patient Centered Cognitive Support” for healthcare providers (see http://curinghealthcare.blogspot.com/2009/06/meaningful-use-clinical-decision.html). This vision goes well beyond the questionable validity of many of today’s provider rating websites.

      As with the other attributes of the Value-Pricing model I’m proposing, I contend that a primary strategic focus moving forward should be on how best to address such issues from economic, clinical, social and technological perspectives.

  • doctor1991

    I will just say that I think Kevin has made some very astute observations. I would also add that the income figures quoted seem very inflated to me- I am a specialist but know few primaries if any making that money- and many NOT making six figures.

  • http://www.healthbeatblog.org maggiemahar

    Stephen and Doctor 1991

    I agree there is a huge difference between “consumer-directed health care” (which suggests that patients are customers and that caveat emptor applies) and “shared decision-making” (which is based on mutual trust. )

    Your vision of “patient-centered cognitive support” sounds interesting. I do agree that if doctors had good access to digestible bits of comparative effectiveness reserach that they could share with patients, this woud be useful.

    Patients generally trust their own doctors and so would listen to them if they could present the evidence in a clear way.

    Doctor 1991–

    I gave you the lnk to the source for these numbers. It’s Medscape’s report — a professsional suvery of thousands of physicians.

    i would point out that where you live –and the practice setting helps explain differences. Doctors in the Northeast earn less than primary care doctors elsewhere. And doctors in private practice earn significantly less than those in mutlispecialty health centers.
    Doctors in private practice are also more likely to feel that they are not adquately compensated.

  • Penny

    Wow, well said! Better words were never spoken! You wouldn’t believe the province of Alberta, Canada is in because politicians are trying to control everything! The public wants an open medical inquiry and the polticians are refusing. Time to get rid of politicians.

    • Penny

      Sorry, that should’ve said, “wouldn’t believe the mess”

    • Joe

      I agree Penny. I think we should just give to doctors a set amount of money and they should collectively figure out how best to provide the best healthcare for all of us within the amount of money we (as a citizenry) choose to pay. If someone wants more, then they can pay for it. I’m afraid we will only get to the point of nationalizing hospitals and healthcare when things really get bad, like in the next depression. So the way things are going now, the system will be forced to that extreme.

      • Joe

        Actually, I think it best to run a VA-like system for all.

  • Greg

    FYI
    Most people don’t realize that CMS (medicare / medicaid) pays for 90% of all US trained resident and intern (split between their salary and to the Hospital that trains them) about 100k a year

    This 400k gift is why they are paid less for medicare and medicaid patients over the course of their career (ie they are paying back that grant/loan)

    The only “cost” is for their actual medical school and if they choose to go to a private vs public school (10k a year) why should society pay for that choice?

  • Alex

    First. I agree with the idea that physician pay should be weighed both ways, but when talking about labor shortage and pay you should mention the certification of allopathic schools of medicine.

    Secondly, you make it sound like physicians are not represented well in health policy debates. You are most likely a member of the AMA!

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