Monday, October 27, 2008

Challenges Ahead for Specialty Care Doctors

As the election nears, both political parties have plans for leaving "no person left behind" when it comes to health insurance even though the costs will be exorbitant:
If the victorious candidate presents his health-care plan to Congress, such optimistic projections will face a stern test at the Congressional Budget Office, Congress's fiscal scorekeeper. The office's estimate of the actual cost of the plans would form the basis for debate, and legislators would face a huge barrier approving any plan assigned a $1 trillion-plus price tag over 10 years. (emphasis mine)
I just returned from a strategic planning committee of the Heart Rhythm Society in Dallas that was tasked with trying to anticipate the impact of the current economic and health care crises on our specialty. The mood, needless to say, was somber. The threats to our subspecialty (and I'm sure of many others) are keen as Congress moves to increase expenditures to primary care at the expense of specialists and subspecialists. One dean of a medical school even commented this weekend, "When the Congressional Budget Office knocks on my door and approaches me about where they can cuts and shift costs given a budget-neutral environment, which is easier, cutting funds to a subspeciality with 1600 members nationwide or cutting the funds from the many family practice or internists out there?"

So while most doctors will appreciate the near flat Medicare payment schedule secured by Congress this year, specialists still have to worry that change is in the wind.

Only by understanding the value of specialists and subspecialists in terms of expertise, safety and patient care outcomes are subspecialist services likely to survive, or even thrive, in the current climate. The onus will be on each subspecialty's lobbies to define such things as competencies, safety, and outcome records and present them for consideration to governing bodies. Clearly for smaller subspecialites, this is a particularly expensive and time-consuming endeavor as each subspecialty fights to maintain some portion of the Medicare payment pie.

Americans, however, will continue to demand subspecialization in medicine for the foreseeable future since they recognize that subspecialists play an important role in their health care delivery. It is impossible for general practice and primary care physicians to understand and implement subspecialty care in today's complicated and litigious health care environment. But as efforts continue to shift dollars from subspecialist to primary care, there exists a potential for losing subspecialists. In fact, 10% of electrophysiology training positions were left unfilled this year. What will this mean to patients? What does this mean to hospitals who are counting on electrophysiology to be their piƱata of Medicare dollars to fund their next wing expansion? Why are doctors not committing to the rigors of our subspecialty? Is the market saturated or is this an aberration?

It is unclear.

But one thing is clear, you can't rob Peter to pay Paul without an impact to speciality care delivery. With the expanding elderly population, existing subspecialists will be stretched to maintain service expectations and their lobbying clout. Young doctor professionals will wonder if all those years of delayed gratification to gain expertise are really worth it. And as the cost of training increases and reimbursement to specialists decline, look for a consolidation of subspecialty care in America while new doctors reconsider their career trajectories.


1 comment:

The Happy Hospitalist said...

Robbing Peter to pay Paul. You said it best. I don't believe the solution is possible in the current Medicare model. When you break out the cost of treating patients, you note that 5% of our population spends 50% of our money. If you want to fix health care, you have to make these people fare less expensive to manage. But that's a trillion dollars a year going into the coffers of everyone taking care of these 5%. They are like gold mines of unlimited glitter and gold. There in lies the key to saving our country from the looming disaster. The issue isn't access. It's making health care and managment less expensive. Consuming less resources. When you have 7 doctors each managing their own area of expertise in a fragmented care model where each is trying to generate revenue on the backs of the American tax payers and private insurance companies, each will each miss subtle clues to decompensation and complications of management that leads to hospitalization. Each playing ping pong with a patient, who has no idea what's gong on. If you want to increase the pie for carrying for patients, you have to decrease to total cost of carrying for them. And that means new care models. I don't believe we can continue to provide fee for service for these expensive consumers of our Medicare and private insurance dollars. They have made insurance too expensive for the other 95%. They must be removed from the equation. I blogged about it today, in case you are interested. The 5% Are Killing Us All