Thursday, July 2, 2009

Zero Sum

Well, it's official. The Obama administration is going to steal from Peter to pay Paul. After months of speculation, the reality is that reimbursement reform will indeed be a zero sum game. From the WSJ:
Under the proposal, Medicare would put specialists' payments for evaluating and managing illnesses on par with those of primary-care physicians starting in January.

That, combined with other changes, would boost payments to internists, family physicians, general practitioners and geriatric specialists by 6% to 8% next year, said the Centers for Medicare and Medicaid Services, the agency that manages Medicare, the federal insurance program for the elderly and disabled.

Payments to cardiologists would be trimmed by 11% overall, but certain procedures they perform would see steeper reductions. Alfred Bove, president of the American College of Cardiology, figured that cardiologists would receive 42% less for an echocardiogram and 24% less for a cardiac catheterization.

Radiologists would see an estimated cut of 20% for imaging services using expensive equipment such as MRI and CT scans, said Bibb Allen, chairman of the commission on economics at the American College of Radiology. That would be in addition to the cuts imposed on radiologists under a 2005 law, he said.

Well it's not a horrible idea. Primary care physicians are certainly undercompensated compared to their subspecialist brethren. They ought to get paid more. Make it financially viable for them to actually spend more than 5 minutes with a complicated elderly patient.

But let's honest about something; these cardiologists and gastroenterologists and rheumatologists are not materializing out of thin air. The radiologists aren't all sneaking into the hospital at night and ordering ridiculous MRI's on all the inpatients. Cardiologists aren't putting ads on Craigslist for cardiac catheterizations. Someone has to order the MRI. Someone is shotgun consulting all the specialists in the hospital. Invariably that someone is the overworked, underpaid internist or family practice doc. So by all means, pay them more. Compensate them in such a fashion that will encourage more comprehensive, individualized care of their patients. But it can't be business as usual. If the reimbursements are going to be shifted toward the primary care docs, then there ought to be a concomitant shift in responsibility for the delivery of care and an increased awareness on the part of the PCP's of the cost of said delivery. No more shotgun consults. No longer ought it to be acceptable to admit patients at three hospitals (running up gargantuan inpatient censuses)in order to drum up revenues and then shunting the responsibility for the care of those patients onto specialists. Pay them more at the expense of consultants/proceduralists? Fine. We've seen this coming. But they're going to have to work harder, not in the sense of longer hours or greater effort, but in the sense of dealing with the practice of actual medicine on their own. That gastroenterologist perhaps isn't going to be as available ten years from now to help you out with that pain in the ass patient with chronic benign epigastric pain. And maybe the general surgeon won't be able to see that patient with a small infected sebaceous cyst stat like before. It sounds nice to better remunerate those primary care physicians who represent the backbone of the American health care system. But it won't come without a cost...

10 comments:

platensimycin said...

i fail to see such proposal in negative light.

#1 Dinosaur said...

Fabulous! I won't have to change a thing about the way I practice right now. I'll just be able to make a reasonable living at it.

The only difference is that when the patients self-refer to the cardiologist for their uncomplicated HTN or the GI for that benign epigastric pain I've worked up three times in the last decade, mayb the specialists won't be so eager to steal them from me and keep seeing them every six months "for follow-up."

Frank Drackman said...

Docs send you Stat infected Sebaceous Cysts?????
I can understand the Internists or Radiologists not wantin to take a knife to somethin...but I'll bet some of these come from Board Certified Family Docs too.... Jeez, in training these were 3rd year cases...3rd year MEDICAL STUDENT cases....

Frank

Anonymous said...

Interesting. I wonder how this will play out. There aren't too many IM,FP,GPs that can "ride rough" anymore. I am sure that the ones that always have will welcome the recognition. Cardiology is really gonna feel the squeeze.
-SCNS

Anonymous said...

malpractice insurance needs to be adjusted accordingly; quality of patient care & autonomy, preserved, too. they are interconnected.

i can see how surgeons can be caught in crossfire - it's sort of nuts to collectively call surgeons and dermatologists as "specialists."

there's no perfect solution, but we need to delete as much monetary incentive as we can from medicine. doctors should work with regulators to set the tone and preserve both the quality and the viability (sanity too) of medical practice beyond immediate horizon.

HudsonMD said...

Once again i feel bad that you are surrounded with inadequate GP's where you work. It's not like that everywhere. I feel i saved the gov't money recently. Patient with known A-fib comes in with A Fib with Rapid Ventricular Response. Put him on cardizem gtt. He converted. Increased his beta blocker and sent him home within twenty four hours. No echo (just had one in february) and absolutely no cardio consult. I am an Internist. This is what i do.

DKV said...

I just spent 45 minutes combing through some .gov documents until I came to the appropriate table.

Some specialties are in for a big hit. RadOnc -19%!

Many are level or small increases.

Page 716 of this document:
http://www.federalregister.gov/OFRUpload/OFRData/2009-15835_PI.pdf

Trader Bob said...

Your money went to the bankers at Goldman Sachs. You want to talk about people that are worthless and overpaid. The bankers bankrupt the banking system and then ask the tax payer for a bailout. Via AIG we the taxpayer paid Goldman Sachs billions. I wonder how they reported record profits in the middle of the greatest recession since the 30's. Good article from Rolling Stones magazine attached.

http://watch.bnn.ca/the-close/july-2009/the-close-july-2-2009/#clip189690

Buckeye Surgeon said...

What the reimbursement reform is going to demand is that more internists/FP's practice medicine along the lines of Dinosaur and Hudson....not a bad thing.

Anonymous said...

Robbing Peter to pay Paul will Peter sore and ther is not much you can do ........