Saturday, December 26, 2009

Outsourcing health care?

Dr Scott Gottlieb had a piece in the WSJ yesterday about the threat posed to physicians with coming health care reform. This paragraph jumped out at me:
Primary-care doctors who refer patients to specialists will face financial penalties under the plan. Doctors will see 5% of their Medicare pay cut when their "aggregated" use of resources is "at or above the 90th percentile of national utilization," according to the chairman's mark of Section 3003 of the bill. Doctors will feel financial pressure to limit referrals to costly specialists like surgeons, since these penalties will put the referring physician on the hook for the cost of the referral and perhaps any resulting procedures.

And I'm wondering, why is this a bad thing? Shall we continue with the status quo of unabated mass-consults where a patient gets admitted to an internist's service and ends up with consults from surgery, GI, ID, and renal; all for a demented little nursing home lady? Financial pressures have a way of altering behavior the fastest. The fee-for-service quandary is contingent on the referral patterns of primary care doctors. The more they are penalized for farming out complicated patients to subspecialists, the less likely that clinical paradigm will continue. And I'm not talking about the patient with appendicitis or the older guy with guiac positive stools. Those patients justifiably need specialist consultation. But does every type II diabetic need an endocrinologist? Does ever obese patient with rickety knees need referral to an orthopod for joint replacement? Does every patient with a perianal abscess need an Infectious Disease consult?

There's plenty to go after in this unwieldy health care reform bill, but this isn't one of them...

18 comments:

Anonymous said...

Amen. 30% of my practice has become the CYA "breast lump/pain" and the surgical yield for my clinics is about 30% yet the time to be seen is about 30 days. Hopefully this will encourage better utilization of resources.

Michael Kirsch, M.D. said...

I disagree that primary care physicians shouldn’t be able to deal with appendicitis. Internists, with some encouragement from the cost-cutters in D.C. should buck up, grab a copy of ‘Surgery for Dummies’ and a scalpel and do their part to save health care. With regard to your point about consultomegaly from primary care docs, some of these guys are following so many patients, that farming out to specialists is the only option.

#1 Dinosaur said...

Great idea! Now all you have to do is:

1. Make sure I get paid enough taking care of all those patients myself that I don't go broke, and:

2. Find a way to assure that all those patients demanding consults won't sue me when I say "no".

I'm happy to manage diabetes, CHF, hypertension, and even drain the odd abscess and remove little lipomas. It's the patients demanding the endocrine, cardiology and surgical consults. Now you want to make me financially liable for their entitlementiasis? Fix the rest of the system -- including the patients' unreasonable demands -- and I'd be happy with your scheme.

ParatrooperJJ said...

Unfortunatly patients who actually need to be seen by a specialist will end up not being referred also.

Buckeye Surgeon said...

Dino-
Sarcasm duly noted. I agree that penalizing over-consulting physicians without fixing the payment scheme for cognitive medicine is insane. But my only point here is to highlight the disingenuous of the op ed in the WSJ. Patients aren't going to be hurt by limiting how many consults they can get, which Gottlieb seems to suggest. We need to be better about when we choose to utilize our specialist resources; no one can honestly argue with that. But we need real reimbursement reform that will make this possible....

Frank Drackman said...

Psssttttt
Do you know how easy it is to do Epidural Steroid injections???

Or to figure out which strength Fentanyl patch to use...

OK, some of the facet blocks are a little tricky, but they never work anyway, at least not any better than placebos...

Whatever happened to the 80's when the Surgeons would send Pizza over for prescribing their high priced medications..
Oh yeah, those were the Drug Reps, but the Surgeons used to do it to...

How bout them Browns!!!

Doctor D said...

I'm all for primary care doing the basic stuff before calling in the specialists, but I'm not sure a rule like this would accomplish this.

Lots of primary docs would just refuse to take on more really sick folks with disease that will require specialists. The primary care docs that did take the very complex patients would get punished for their good deeds and more really sick patients would be high and dry, and probably showing up at the specialists' doorstep anyway.

They'll probably just end up saving money by decreasing specialist compensation. They've been doing it to primary care docs for years, which is one of the reasons a lot of PCPs push work off on specialists.

j said...

Is there some kind of time/$$/"reasonable" (lol) limit to the 90% thing? Because logically extended it means that eventually PCPs will be penalized for any referrals out.

I must be missing something big here (I have a huge headache which isn't helping, of course).

ParatrooperJJ said...

Of course patients are going to get hurt. If referrals directly effect a internist's bottom line, they will most likely make fewer referrals.

tom said...

Another rule, and one linked to $ now that sounds like another level of doctor watchers added to what exists currently.

How about this idea...personal responsibility. If something is bothering me and my primary care doc says 'forget about it".. I pay for the referral. Anon doc says 30 % of his practice is CYA with low yield and long waits. What if those were all cash patients? Problem??

Time for us to wake up to the root casue of many illnesses-the patient's chosen lifestyle that somehow get interpreted to be the doctors fault?

More doctors will say no, when the trial lawyers are told no.

encdinosaur said...

In my experience, most of the consults that I see occurring seem to be referrals from one subspecialist to another subspecialist.

I really enjoy trying to keep up with my patients who, at an age and with multiple medical problems would be poor surgical candidates, self referring to an doc-in-the-box, only to be seen by a PA, then get referred sequentially to an orthopedist, a neurosurgeon, and then a "pain specialist" after multiple imaging efforts ordered for the benefit of the radiologist, only to be put on a pain medication that increases their confusion and falling!

As a general internist with an aging medicare patient panel, just trying to keep up with those referrals causes headaches! Trying to manage multiple diseases at on time, avoiding conflicting medications, therapies, and side effects, is hard enough without the confusion.

But don’t blame me or hold me accountable unless I have some tort protection and respect, in many forms, for what I do!!

Buckeye Surgeon said...

Agreed: tort reform and payment reform are necessary conduits to enforcing cost efficient physician practice patterns...All three components are necessary.

rural_obgyn said...

I'm all for primary care docs doing everything they can. Yet I keep remembering the lady with postmenopausal bleeding whose primary doc did an endometrial biopsy with pathology benign but showing no endometrial tissue. Patient self-referred to me and my endometrial biopsy showed cancer. I do EMBs daily, he probably does one a month.

Michael Kirsch, M.D. said...

To rural GYN, obviously the tumor developed after the primary MD saw the patient, right?

Anonymous said...

that's right, punish primary care. Nothing new here. More reasons to leave or not go in.

How about increasing co-pays by patients for specialists. That's how it is done in France

Anonymous said...

if you consult you are penalized and you do not recieve payment for your time and training. If you do not refer and you miss something you will be sued with no defence and lose money for trying to spend less money to fullfill a public health policy you have no input into. This will be added to my list of unfunded mandates. I made my choice. I quit when my accountant informed me that my job was now considered a hobby by the IRS.

Anonymous said...

So what, exactly, is the primary care giver's responsibility to properly diagnose and refer a patient to a specialist before reaching the end stage of a disease, for instance, chronic renal failure at Stage IV or V, requiring dialysis? This is a silent disease which is diagnosed with lab results that are not easily deciphered by the lay person who is a patient. Isn't there some sort of moral and professional responsibility of the primary care giver to the health of their patient that is not purely motivated by profit?

Sayuj Banerjee said...

The medical world is not waiting for tort reform, in order to tackle excessive litigation costs. With the rise of offshore legal outsourcing, doctors now are choosing to defend themselves against meritless lawsuits, using both U.S. and Indian lawyers. The offshoring of legal work is leading to a new breed of benign tort reform, as defendants facing bogus or inflated tort claims now can afford to litigate and win. This in turn discourages such claims. And the money that otherwise would be spent by defendants on nuisance payouts can be plowed back into the U.S. economy. That's reform we can believe in!

Sayuj Banerjee
SDD Global Solutions