Sunday, July 07, 2013

Physician Pay Redistribution: A False Sophie's Choice

Sophie's Choice is a novel by American author William Styron, whose plot ultimately centers around a tragic decision Sophie was forced to make upon entering the Nazi concentration camp: on the night that she arrived at Auschwitz, a sadistic doctor made her choose which of her two children would die immediately by gassing and which would continue to live, albeit in the camp.

While not of the same gravity,  I have seen the discussion by policy wonks about physician payment reform evolving into a smackdown between primary care physicians and specialty physicians for the remaining coins tossed on the health care floor.

James Hamblin MD, The Atlantic magazine's health editor, recently published an article entitled "When the Best Hospitals are the Worst," that assumes prestigious hospitals are the "worst" because they fail to train an adequate number of primary care physicians relative to the federal subsidy they receive for training residents:

But many hospitals aren't using that money to do what the taxpayers most need. 158 of them produce zero graduates that go into primary care. The worst offenders, in terms of the number of primary-care physicians produced, are the hospitals we hold in highest regard. 

To bolster his point, he references another article from the July-Aug 2013 issue of the wonkish Washington Monthly by demographer Phillip Longman entitled "First Teach No Harm."  Both Hamblin and Longman claim the following:
The nation’s residency programs are producing too many of the wrong kinds of doctors in the wrong places, while not producing enough of the kinds of doctors we most need to sustain the U.S. health care system.

Specifically, the programs turn out too many specialists who go on to practice in places where such doctors are already in oversupply, and where, according to numerous studies, they often inflate health care spending by engaging in massive amounts of unnecessary surgery and other forms of over-treatment. 

While both Hamblin and Longman make excellent points about the work conditions of today's primary care physician's, they veer into dangerous territory when they pile on the assumption that the problem with our nation's health care delivery and cost problem is the distribution of dollars between different types of physician training programs.  American's need doctors - all kinds of them - thanks to the ever-growing and aging population.  What they don't need is the mushrooming and very costly administrative overhead that plagues physicians today.

Here's a radical thought: all physicians should be paid a respectable and competitive salary commensurate with their years of educational investment and competitive training and receive the quality training they need to do their work.

But rather than acknowledging this fact, Hamblin and Longman want us to make a false Sophie's choice: picking which types of physician training programs should receive federal funds based on the types of physicians they train, rather than working to improve the lot of all physician training programs to assure excellent doctors in the years ahead for our health care system.

Perhaps rather than wondering how to redistribute $13 billion dollars of educational funding for medical residencies that flows to all residency programs, Hamblin and Longman should ask how we should cut the mushrooming and incredibly costly administrative overhead of our system that already  stood at $320 billion (and counting) way back in 2003?  How much is that overhead expanded thanks to the introduction of over 110 government agencies created by our new health care law?  Which bean counter should be fighting with the other bean counters for their share of administrative dollars?  Which new data miner, quality coordinator, hospital administrator, database operator, or government agencies that share similar functions (like the PCORI and AHRQ agencies) yet provide no care should be fighting to save themselves?

Maybe rather than peeling the dollars from any doctor's training pocket as he charges down the hallway to see the next patient in his 14-hour day, we should determine how to peel the even larger amount of dollars held in the pockets of the five administrators trailing him.

This is our real health care system cost Sophie's choice.

And doctors of all specialties would be wise to remind Congress and their respective medical associations of this fact.



Anonymous said...

Sooner or later millions of people will have a rude awakening when it finally dawns on them that the so-called affordable health care bill doesn't have so much to do with delivering affordable health care as it does paying the costs of administration.
To me, it looks like the typical, giant, bureaucratic parasite the elected government is so fond of creating.
Thanks for writing, Doc.

Anonymous said...

I don't understand why it has to be an either or choice. We know there is an oversupply of specialists in certain cities and an undersupply of primary care physicians in others. We also know that administration costs are astronomical. However, dealing with of healthcare spending is conprehensive. Curtailing it will have to take into account how many and what types of physicians we train, limiting administration costs, how we reimburse, who pays, drug costs etc. At some point we'll have to face all these choices, not just Sophie's, whether we like it or not. The sooner the better.