Monday, June 29, 2009

Biasing the Argument Against Specialists

In an article originally published in the Washington Post on 20 Jun 2009 and republished in the Chicago Tribune today, the national shortage of primary care physicians is highlighted and serves as a significant problem for health care reform efforts underway. The systematic devaluation of primary care relative to "procedural-based" medicine is again addressed:
The disparity results from Medicare-driven compensation that pays more to doctors who do procedures than to those who diagnose illness and dispense prescriptions. In 2005, for example, Medicare paid $89.64 for a half-hour visit to a primary-care doctor in Chicago, according to a Government Accountability Office report. It paid $422.90 to a gastroenterologist who spent about the same amount of time performing a colonoscopy in a private office. The colonoscopy, specialists point out, requires more equipment, specialized skills and higher malpractice premiums.
But, as mentioned previously, we should realize that Congress made attempts to correct this disparity though "fudge factors" to the RVU payment formula before:
In 1993, Congress declared a redistribution of funds from proceduralists to primary care physicians. Initially there were 2 conversion factors—1 for medicine and 1 for surgery. The conversion factor, ie, the multiple of the RVU for payment, had the added advantage of demonstrating where costs were increasing. The 2 conversion factors demonstrated conclusively that surgeons did not increase their utilization when reimbursement decreased (because, for example, patients have only 1 gallbladder, and the indications for its removal remain constant). Other specialties increased their utilization, a process that continues to this day. In a refining effort to shift money to primary care, a third and separate conversion factor was developed in 1995. By 1997, it was clear that separate conversion factors were not controlling utilization of primary care and medicine services, causing these 2 conversion factors to decrease. The 3 separate conversion factors were eliminated in 1998, resulting in a decrease for surgery and an increase for medicine and primary care. In addition, more surgeons' practice expense reimbursements are included under the indirect category, now reimbursed at 35% of cost; internists and primary care physicians have a higher percentage included as direct expenses, which are reimbursed at 66%.
But few mention these facts. Further, when payment differentials are cited between primary care and specialists (whom have been conveniently reduced to "proceduralists"), the 90-day global period (the surgery and all care related to the procedure for 90-days afterward) is rarely, if ever, mentioned in the discussion. Follow-up visits, dressing changes, wound checks, and management of complications - all conveniently ignored pre-paid for three months.

Without a clear understanding of all of the issues related to physician compensation and the problems with government's prior attempts at meddling with the system to correct the disparity between primary care physicians and specialists, we should understand that simply cutting specialists' fees in favor of primary care physicians might lead to not only additional primary care shortages, but an even more acute shortage of specialists as well.



Keith Sarpolis said...


Your point is well taken that attempts by the goverment to regulate the payments for different services is less than perfect which leads to undervaluation of some services and overvaluation of others. The market acts appropriatly by giving more of those things that are more profitable (but not nesecarily adding value) and less of those that are not.

The Dartmouth data are being touted more and more as the data that proves that where there are more specialists, you get higher costs, and in some cases even worse outcomes. Primary care tends to corelate with less costs with the same or better outcomes. How would you explain this if not for overutilization of more risky diagnostic testing or procedures?

Your example of the gallbladder ignores the true indications for cholecystectomy. While true that patients only have one gallbladder, the question would be how many had inappropriate surgery for a diagnosis of cholelithiasis detected incidentally on imaging without evidence of cholecystitis?

While the scope of codes that have been added in the past years has expanded for procedures, they have not for cognitive services, this has shifted the amount of the pie to specialists and proceduralists. Despite all the tinkering you mention, the creation of limits on the amount of funds that the total pie of physician services can rise, has been limited by the sutained growth factor. Thus, when you do more ICD implants that have been now indicated for cardiomyopathy, but were not till more recently, it pulls funds away from every other service. And when radiologist recommend a secondary imaging test for every CT or MRI, it also decreases the amount that goes to those other codes not dealing with imaging. We are essentially in a battle between ourselves for who gets the biggest piece of the pie. I think it is pretty clear who is winning this fight!

Finally, your indignation with the term proceduralist is one I understand, but from my view, it is becoming one that is more deserved. Because cognitive visits reimburse so much less or are bundled into a surgeons global fee, they have employed nurse practitioners and used hospitalist to do the daily visits and follow up of patients that they used to do. This defines what I would call a proceduralist which is the physician who does his procedure and then seemingly disappears. It seems our orthospedic colleugues have perfected this to a fine art in that I rarely see them come back to see their patients post operatively. And why would they if they make considerably more spending their time in the operating room than seeing patients on a hospital floor? Not all physicians who perform procedures do this, but it is a more and more common practice to the point that I rarely encounter a proecedural based specialist when I am doing rounds at the hospital anymore (nor any primay care docs for that matter!)

DrWes said...

The Dartmouth data are being touted more and more as the data that proves that where there are more specialists, you get higher costs, and in some cases even worse outcomes.

There are significant limitations to the Dartmouth data - the largest being that they only include data from Medicare beneficiaries. That being said, the whole argument of "less cost with better outcomes" falls flat when we consider say, complete heart block. If a primary care person was to treat that, rather than a specialist, I can ASSURE you (as you say), the patient's care would be cheaper because they'd likely die without a pacemaker implanted. Where's the moral outrage to this argument, Keith?

No matter what I do in the EP lab, I still have to use the facility with all of it's regulatory requirements, the expensive pacemaker, the sterile instruments, and the staff. To think that primary care is going to somehow make all these costs disappear and make medicine suddenly affordable is nothing more than a talking point.

Further, to suggest that primary care doctors are somehow more angelic that specialists - aren;t they just a "guilty" screening for all that hypertension, hyperlipidemia, and diabetes out there? How many more patients do you follow monthly, biannually, or annually in the name of "quality care?" Are all those visits necessary?

Finally, to suggest that specialists don's serve a role in "cognitive services" is insulting to anyone who has subspecialized. How much do you know about defibrillators, their debugging, or the differences between models, recalls, the contraindications and potential complications when implanting one in a nephrology patient. Not to say that these things can't be learned, mind you. But we all have our own areas of expertise - mine just involves more expensive equipment that society (and our regulators) have decided warrants the cost, all in the name of safety and "quality."

By the way, don't get started on the "I never see specialists in the hospital" stuff. You and I know that's a bunch of BS. Many specialists these days are working at more than one facility and are under ever-increasing pressure to "produce," usually with "productivity" clauses in their contracts tied to MGMA "benchmarks." As such, they are the gerbils, not the wheel.

The bottom line: you simply can't get something for nothing. Ever. Physicians, while important to this debate, represent only about 8-15% of the health care dollar - redistributing their income is NOT, repeat NOT, going to shave health care costs substantially. Period.

Keith Sarpolis said...

Dr. Wes,

Seems I have touched a nerve here.

Regardles of whether you travel to several hospitals or not, does not explain why you don't see any docs on the floors anymore (except for hospitalists). I think the problem here is some tranference of anger from what others are telling you you need to do vs what you would prefer (I personally discovered the insanity of trying to go to multiple hospitals and wouldn't try) Presumably when you get to that other hospital, don't you go see the patient on the floor? Travel time is what eats up your time and I think you need to talk to the boss about that. I was on the surgical floor this AM with no one with an MD degree in site. Lots of nurse practitioners scurrying about however! It is this kind of delegation of this care to mid level providers that is aiding the destruction of primary care by sending the signal that you don't need an MD degree to take care of patients post operatively or otherwise. You only need an MD degree to poke a hole somewhere in their body. This is tantamount to what has happened to nursing where we have nurse assitants to perform the patient care while the nurses only pass the meds; but the problem is that those mundane activities that nurses used to do represented an opportunity to assess the patient at the bedside by an experienced health care worker.

To state that the Dartmouth data only include Medicare I will grant you, but to think that this data cannot be extrapolated to the entire population is a rather untenable position. Especially since most specialties and procedures are performed on the Medicare population.

It is true that what you do in the EP lab will not lower costs elsewhere, but my point was that under this system that neither you nor I created, every time some new expensive procedure comes on line, it lowers the payment for for older services like office visits. Primary care has had no new service code to add in years, so we have been slowly devalued over time. The specialist response has been to hire your nurse practitioners and have them do all this now undervalued work. Why were these important physician services before but are now delegated to nurse practitioners and such? Because specialists have more lucrative ways to spend their time than talking to patients!

The incentives to do more and offer more exist under a fee for service health care system and that is why we should move away from this model of delivering health care. Abuses in the overdelivery of services exists in primary care as well as specialties. It is just alot more expensive when an EP guy puts an unnesseary pacemaker in vs a primary care doc who has a patient back for an unneccessary office visit. The truth of the matter is the bad actors can increase their efficiency by spending their whole day putting pacemakers in while they have their nurse practitioner doing the post procedure care and follow up.

Anonymous said...

As compared to all other college graduates, the medical field is quite different in requirements and I wonder if the average citizen knows what makes a GP or FP different than speciality physicians.

I hope that most know that in addition to having to have higher grades in college, those choosing most medical fields must pass testing and then go on to further studies which takes an additional 3to 7 years. But just like other graduate studies there are choices to be made within these studies as to what particular area one will apply their knowledge and skills. And after these are concluded most choose to be "ranked" within groups as physicians encourage the endorsement of their peers wihin each specialty.

So can a GP or FP do a heart transplant, remove a brain tumor, or perform plastic surgery? You don't want to know!

Can cardiologists,OB/GYN, neurosurgeons, and all specialty physicians do the tasks performed by the FP and GP? In their sleep! In fact they do all of these plus more as they treat their patients.

In addition, the specialists start early and are not on the golf course every afternoon and all studies show that their skills improve based on the number of procedures they perform. So the number of specialists currently serving have proven their value to our heakth system.

My question therefore is does it a FP or GP to order most of the tests and procedures that take up the majority of the time [except the long waits] during visits? In most cases I suggest, physicians do not do any of them but rather they are done by a nurse or other lesser trained but still licensed providers. If these processes were done at lower levels and perhaps other locations, it could greatly increase efficency in doctors offices.

Providing more money won't change a thing, unless physicians chose their specialties based on a slightly higher government fee which would still be lower than fees paid to specialist. Does anyone believe that a cardioligist that does 3 or 4 bypass surgeries each day would rather be seeing 100patients, screening for Swine Flu?

But the real facts are that we need more medical professionals and the only way to get them is to open the ways to produce more of them, which by the way will take some 10 years to accomplish, for that is how long it takes to "fill the pipeline!

Anonymous said...

what time were you on the surgical floor dr keith? i am usually rounding at 5 am and i don't see too many of the internists there at that time. many of the internists don't round any more in the hospital either.
since i can't be in two places at once, if i'm operating and someone on the floor needs something, either they wait till the end of the day or my extender goes to see them and starts an evaluation or answers questions. patients generally appreciate it. it is not because i don't think it's important, it's a fact of life for me since i'm the only one in my specialty in my town. in fact i appreciate it enough to pay money out of my own pocket for it as the extender does not bill anything. their presence does not allow me to do more surgeries since i have to do them anyways (too much work--and yes, the work is indicated). it does allow me to leave for home earlier.
i disagree that the dartmouth data can automatically be extrapolated to non-medicare populations.

Keith Sarpolis said...

Anonymous (whomever you are),

I grant you I do not patrol the surgical floors watching to see if surgeons are seeing their patients. I commend you for still paying a visit to see your patients post op, although the most common question I get from post op patients is what happen to my surgeon; I haven,t seen him/her since the lights went out. I realize that surgeons tend to dwell in the surgical suites, but nevertheless, something has changed over the 20 plus years where I just do not see you folks anymore. Do all of you round en mass at 5 AM and then disappear to the lower confines for the rest of the day?

It cannot follow that despite years of data collection by the researchers at Dartmouth, you don't seem able to accept that this data can be extrapolated. There must be something terribly unique about the Medicare population that makes this an imposssible thing to do. I guess we need to have someone collect data on the ENTIRE health care system for 20 years before you can be convinced of the validity of this data. Anything to delay meaningful health care reform so the orgy can continue.

Anonymous said...

i am anon 9:54
i do not have the background to be able to appreciate the dartmouth data to be as definitive as you find it. if my experience was such that it confirmed my observations, i would likely find it more believable.

my wife is a general internist. i appreciate general internists and have the highest respect for them. that said, my own experience in several practices is that the majority hold on to things too long before sending them for evaluation. i don't know if they discount the symptoms or are too busy to listen or don't want to admit they don't know something or think they know more than they know, but a humongous workup is initiated, usually by the primary doc. they arrive at my doorstep and then after spending time listening to their focused complaint and examining them, we discuss a course of action. since i have so much more time to go in depth on the problem at hand, and since i have more frequent encounters with the problem, the patients usually are pretty pleased with this. had they come earlier in their evaluation, the patients likely would not have been tested up the wazoo, they would not have experienced symptoms for so long, and they (imo) would not feel like the primary doc didn't know what they were doing.
we see fiercely independent docs who seem to think they can do everything. we see some young docs who don't have the experience to handle things yet trying to handle too much. sometimes they are overconfident, sometimes they are underconfident but think it is like residency where they will be laughed at if they ask for help. sometimes senior docs have not kept up with the literature. anyways, i'm not casting stones since i went through all that myself as a young doc and likely will go through all that as a senior doc, but to say the specialists are costing the system is not at all clear to me. i would like to see how the data is parsed to understand the dartmouth data.

i am a frequent referral source to mayo clinic. they are kind enough to allow me to observe when my patients undergo procedures. i have no idea how they can claim they are cost efficient when from the specialist side they repeat every test and they seem to do more advanced surgeries to all patients. my subjective opinion is that they don't feel bound by guidelines, they are testing to see whether guidelines should be changed and so they test more aggressively. they do procedures more aggressively. i certainly have seen my own patients not be treated according to guidelines (and agreed that the treatment was appropriate).
the hospital has jillions of employees and teams to do things that no other hospital in the country has. they have all the newest toys. they have more people to collect and parse data than i can imagine. there is no way they could survive imo without external support from donations and grants. i think the data is presented to support the contention that they are cost efficient, but i really really can't see it.

lastly, i hear what you are saying about patients not seeing their surgeons. i know it is happening, but i don't think it happens more than patients not seeing their primary docs whose clinic is not in the hospital. those guys round at 7 and disappear not to be seen again until next morning in my experience (i totally understand why, i'm not blaming them). this is where the hospitalists can really help to keep patient and families (and sometimes it is the family who needs to be reassured more than the patient, as you know) happy. what i mean is that they complain about the surgeon to the primary doc and they complain about the primary doc to the surgeon.

anonymous :)