Is there a role for doctors in the brave new health care world?

Like most of my age cohort, I was brought up to believe that the great Satan threatening to undermine the bloated American health care system was our broken-down, antiquated, self-interested model of reimbursement for care provided called “fee-for-service.”  Being a professional who, to the best of my ability, tries to maximize the value of the care I provide to my patients, I subscribed wholly to the notion that the cause of our exploding health care cost conundrum is driven entirely by me  and my physician brethren.

We order too many tests and perform too many procedures.  We do this because we are motivated by greed and profit.  The financial incentives to do more,  to pad our bank accounts, to renovate the spare bedroom in our Cayman Island vacation homes, to rip out the tiles in our master baths and replace it all with gold embossed marble, to book a window seat on the next Space X shuttle to Mars, to become minority owners of professional sports teams, simply drives us to do more and more and more, whether our patients need it or not.  Ask not if the patient needs a new Stryker mechanical joint, rather ask “does the patient have knees.”  We have been told this time and again.  Battered over the head like the self-obvious cudgel it ought to be.

To wit:

Kaiser Family Foundation: “Most insurers — including traditional Medicare — pay doctors, hospitals and other medical providers under a fee-for-service system that reimburses for each test, procedure or visit. Coupled with a medical system that is not integrated, this encourages over-treatment, including repetitive tests, the report says.”

Robert Wood Johnson Foundation:  “Accordingly, reimbursement under a FFS model generates a strong incentive for a high volume of tests, procedures, inpatient stays and outpatient visits, including those that have questionable potential to improve health.   The incentive to generate income by performing more tests and procedures is exacerbated by having the costs typically paid by a third party insurance, masking the true cost to consumers.”

Ron Wyden: “Pay-for-procedure or fee-for-service reimbursement rewards doctors and hospitals for volume — not keeping patients healthy or being efficiency. Pay-for-Performance is clearly one tool that can change the incentives to reward quality.”

CBS News: “A systemic driver of high costs is America’s fee-for-service health care system, in which providers are compensated for each procedure, not for the outcome of care. This system provides providers an incentive to pad their bills by performing as many services as possible, while providing no incentive for patients to decline unnecessary procedures.”

Center for American Progress: “One of the key reasons for the high level of health care spending and its rate of growth is the predominance of the fee-for-service payment system, which rewards quantity over quality, especially for high-cost, high-margin services.”

Atul Gawande: “The primary cause of McAllen’s extreme costs was, very simply, the across-the-board overuse of medicine.”

And, of course, this: Obama on surgeons and amputations.

It seems clear enough.  Physicians collectively have betrayed their constituents.  We, as a professional guild, have yielded to crass, craven materialistic pursuits.  The way of the future is the accountable care organization, an amorphous hive-mind of specialists and sub-specialists who act in concert, an intellectual symphony of elegantly intertwined collaborators who then split up the paltry reimbursements like Trappist monks dividing the fall harvest for winter sustenance.  Further, the dawn of the age of value-based purchasing is upon us.  Remuneration will become 80 to 90 percent outcomes-based.  Are you opposed to paying only for quality?  Then you must agree that it is immoral, heinous, unconstitutional even, to pay for a medical intervention or treatment if the outcome does not lead to complete restoration of optimal health within 30 days.  You must.  This is not debatable.  There are bounds to the limits of what is considered acceptable discourse in the realm of health care reform.

Sure there are inconvenient facts that only seek to cloud the one true perception of what is wrong with American health care.  Facts can be propagandized.  Truths outside the parameters of TRUTH will not be tolerated.  The following will be used by the undesirables to bolster claims of innocence and cynically direct one’s attention to other targets of cost-containment:

  • Reimbursement for general surgical procedures, like inguinal hernia repair, have gone down 20 to 30 percent (in nominal dollars) over the past 15 years.
  • Hospital charges quadrupling surgeon fees for outpatient procedures.
  • The robust profit margins (15 to 25 percent) of big pharma, medical device makers, and the biotech industry.
  • The bloated growth of hospital administrator bureaucracy compensation. (Six-figure salaries for mid-level community hospital VPs of quality assurance or whatever.)
  • The fact that 30 percent of Medicare spending occurs in the last six months of a patient’s life.
  • The opacity of the hospital chargemaster and variability in reimbursements from state to state, town to town.

Disregard all the above.  It only serves to distract from the true villainy occurring every day in individual physician offices and operating rooms.   The true test of a physician’s character depends on his or her willingness to forgo personal remuneration for services rendered.  All compensation ought to be contingent on the final outcome.   Only by disconnecting the physician from any tangible financial benefit will we enter the utopian era of value-based, collaborative health care provision.   After all, the rest of the economy functions along similar lines.  No one pays their plumber to come out to their home for a leaky faucet.  That’s absurd.  We all pay a set, reasonable premium every year for “household expenses” which covers your plumber, heating and cooling guy, roofer, various approved handymen, contractors, etc.

And if another pipe, in the other bathroom springs a leak within 60 days, well, that plumber shows up upon demand to fix it sans additional charge.  This is how we control costs.  we simply stop paying for services rendered.  Because physicians are only out to get into your wallet.  They will not stop.  Without an aggressive counter-attack, they will continue to bill you for that 4 a.m. appendectomy, for working up your chest pain, for diagnosing your breast cancer.  The world has moved past such depravity.  We have arrived at the precipice of disaster and, looking over the edge, a paradise extends interminably before us.  I see a world with only health care providers rather than the unnecessary hierarchical declination from “doctor” to “midlevel practitioners.”  I see bundled reimbursements and capitation.   It is a brave new world of “patient-centeredness” and “accountable care.”  Physicians must fall into place and accept their role as interchangeable pieces, like ever so many Ford workers on a modern assembly line, contributing a small widget to the glorious whole.  The new way strides forth with ineluctable momentum, with or without us.

Jeffrey Parks is a general surgeon who blogs at his self-titled site, Jeffrey Parks, MD.

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