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How Should Doctors Get Paid? – Part 5

Published May 4, 2014 How Should Doctors Get Paid? 11 Comments

A Country Doctor’s Proposal for Health Insurance Reform.

In the forty years since I started medical school, I have worked in Socialized medicine, student health, a cash-only practice and a traditional fee for service small group practice. The bulk of my experience has been in a Government-sponsored rural health clinic, working for an underserved, underinsured rural population.

Today, I will pull together the threads from my previous posts in the series “How Should Doctors Get Paid?” I will make a couple of concrete suggestions, borrowing from all the places I have worked and from the latest trends among the doctors who are revolting against the insurance companies by starting Concierge Medicine and Direct Primary Care practices.

Because I am a primary care physician, I will mostly speak of how I think primary care physicians should be paid.

I will expand on these concepts below, but here are the main points:

1) Have the insurance company provide a flat rate in the $500/year range to patients’ freely chosen Primary Care Provider, similar to membership fees in Direct Care Medical Practices.

2) Provide a prepaid card for basic healthcare, free from billing expenses and administration.

3) Unused balances can be rolled over to the following years, letting patients “save” money to cover copays for future elective procedures.

4) Keep prior authorizations for big-ticket items, both testing and procedures, if necessary for the health of the system.

5) Keep specialty care fee-for-service.

6) Have a national debate about where health care ends and life enhancement begins and who should pay for what.

Health insurance needs to be simple to understand and administer. It needs to promote wellness, and it needs to remove barriers from seeking advice or care early in the course of disease. It needs to empower patients to use health care services wisely by aligning patients’ and providers’ incentives.

Health insurance should not be deceptive. It should not promise to pay for screenings (colonoscopies and mammograms) and stop paying if the screening reveals a problem (colon polyps or breast cancer). It should offer patients the right to set their own priorities for their health while demanding concern for our fellow citizens’ right to also receive care.

Health insurance is not like anything else we call insurance; all other insurance products cover the unexpected and not the expected. Most people never collect on their homeowners’ insurance, and most people never total their car. Health insurance, on the other hand, is expected by many to be like a bumper-to-bumper warranty that insulates us from every misfortune or inconvenience by covering everything from the smallest and most mundane to the most catastrophic or esoteric.

What would it look like if Johnny or Fido puts mud prints on the living room wallpaper and Dad makes a claim on his homeowner’s policy? Or if Sally spills chocolate ice cream on the beige upholstery of Mommy’s new car and the auto insurance has to pay to have the seats recovered?

In today’s healthcare, everything is potentially a covered service, and there are no incentives to limit one’s claims against the insurance companies. I believe we need to make patients view healthcare spending as their business, and the money as their money.

My proposal for payment reform in healthcare can work in a single-payer system or with multiple payers, both public and private insurers:

Have the insurance company provide a flat rate to patients’ freely chosen Primary Care Provider, not the $3 per member per month we used to get from the HMOs of yore but real money. Something in the order of $500/year would be more reasonable for the primary care physician to manage a patient’s health care. This would cover maintenance of a patient-focused and updated medical record, care coordination, management of medication and communication issues, access to medical triage and treatment capacity and one yearly visit for personalized screenings and care planning. For a panel of 1,500 to 2,000 patients, this would bring in $750,000 to $1,000,000.

Keeping in mind that the annual per capita health expenditure in this country is $8,500, that would gobble up a mere 5.9% of the pie. The billing for this would be very simple; just a head count multiplied by the monthly fee. For comparison, physician practices in the United States now spend $82,975 per physician per year interacting with payers, according to the Commonwealth Fund. Roughly speaking, that means doctors spend more than one hour every day working to pay the billing department and to do the free work we perform for the insurance companies. Imagine the improvements in patient service an extra hour a day per physician would make possible.

The advantage with this kind of system is that it would promote shared resource stewardship between doctors and patients. Primary care doctors would be incentivized to maintain large enough panels of patients to get the basic funding, but they would need to maintain patient satisfaction with their service in order to keep that funding.

Like cash-only Direct Primary Care practices, with a financial foundation covering basic operating costs and with elimination of billing expenses, practices receiving insurance money up front can keep the total visit costs low. With overhead already covered, per-visit cost could be almost in line with today’s patient copayments.

I believe that under this model, primary care could do a much better job being responsive to patients’ needs than in today’s $7 per minute hamster-wheel race for the insurance money.

Provide a prepaid card, similar to EBT cards for food stamps, or department store gift cards, that patients can use for the average number of annual visits (3-4) with their primary care physician and a basic amount for laboratory tests as well as “blanket approved” ancillary services like initial visits with counselors, dietitians and physical therapists. Again, no billing, so we could do much more for less money.

Beyond the basic level of primary care, higher copayments and prior authorizations could indeed have a role. Money from the basic allotment not spent in a given year could be rolled over to cover future copays, such as for elective surgeries. This would help reduce the tendency to spend down the account every year with a “use it or lose it” mentality.

Specialty providers should not be paid by capitation, as some people have suggested, because the market forces that would make it necessary for primary care doctors to maintain a satisfied (and healthy) patient population would not work as patients often wouldn’t know how to rate their specialist until they needed the care. By that time it may be too late to “vote with your feet” and go elsewhere. Who would sign up with a brain surgeon, just in case he needed one?

At the risk of offending my specialist colleagues, the hassles of insurance billing and prior authorizations must seem at least a little easier to bear when you make your living doing fifteen minute cataract surgeries for $3,000 each than when you treat complicated diabetes, hypertension and heart disease in fifteen minute intervals for less than $100.

For catastrophic illnesses, like cancer, eliminate copayments altogether and provide monies to reduce barriers to care, like transportation to daily radiation treatments, which can be burdensome on patients and families.

This may be controversial, but we as the country that spends twice what other countries spend on health care need to talk openly about setting priorities. Going back to the example of homeowners’ insurance above, if all my neighbors make insurance claims to essentially pay for redecorating their homes, and my premium goes up, do I have the right, or even the obligation, to speak up and say that they are hurting their neighbors when their claims increase all our premiums?

Some of the difficult conversations we need to have concern the shifting definition of disease in our culture. Things that used to be seen as normal aging or just life in general have gradually become diseases, especially when new and expensive drugs are marketed directly to consumers. This is why I propose that diseases like cancer should be better covered than runner’s knee, benign enlargement of the prostate (and this is a sixty year old male talking) or restless leg syndrome (even though it was described by a Swede from my Alma Mater). Even temper tantrums are a disease now, and I can think of several $200/month drugs doctors prescribe for them. And, by the way, most newer brand-name drugs seem to cost at least $200-250/month. We all need to be aware of what tests and treatments cost, so we can assess their value.

As a Swedish American, I can honestly say that health care with no market forces is not an ideal system, but for market forces to have a chance to work, consumers (patients) must think of the money they spend as theirs, not someone else’s. Before that money landed in the insurance companies’ or Government coffers, it was on the top line of each of our pay stubs. We need a healthcare system that keeps us thinking of our nation’s healthcare budget as our own.

How Should Doctors Get Paid? – Part 4

Published May 1, 2014 How Should Doctors Get Paid? , Opinions 1 Comment

Honest Pay for Honest Work

Times have changed. And it’s time they change again.

In the past, medical care was more episodic than it is now. People went to see the doctor when they felt unwell. Diabetes affected mostly older patients, who didn’t live long enough with the disease to develop complications. There were no blockbuster drugs for high cholesterol, Hepatitis C, fibromyalgia or chronic heartburn; we didn’t manage nearly as many patients on multiple medications as we do now.

In those times, a payment scale based on the length and complexity of the visit made sense, and there wasn’t much doctor-patient interaction between visits.

Today, we manage more chronic conditions, use more medications, do more laboratory monitoring, more patient education, and more administrative work on behalf of our patients than before.

Payment scales based only on what we do in the face-to-face visit have become hopelessly antiquated and stand in the way of the new demands of society – physicians providing longitudinal care for chronic conditions in patient-centered medical homes.

The business reality of primary care is that a doctor in a group practice needs to bring in $400/hour to keep the doors open and the support staff available to do the clinical and administrative work. Insurance billing and waiting to be paid is costly and requires cash on hand. Electronic medical records are expensive to install and maintain.

Insurance payments for face-to-face visits are arbitrarily “discounted”, yet expectations are increasing for providers to render additional services after or between visits. In many cases the extra work is generated by the insurance company:

A new prescription requires a “prior authorization”, but many insurers are secretive about what drugs must be tried before the desired drug will be approved (only a handful of insurers post their preferred drug lists on Epocrates, the central repository physicians can access on their smartphones);

A “pharmacy benefit manager” contacts a doctor to suggest that his diabetic patient should be on an ACE inhibitor or a statin, when the patient is actually already taking them. He pays cash at Wal-Mart because that is less costly than the insurance copayment at the local drugstore, so these drugs don’t show up in the insurance company claims data;

An insurance company writes to alert a doctor that a patient on expensive medications may be noncompliant with his regimen because he has only used 60 days’ worth of medicine in the last 90 days. That’s because the kind doctor slipped the patient enough samples to save him a copayment once or twice;

A prior authorization unit demands a “peer-to-peer” telephone call before they will authorize an imaging study. All the information required may be in the medical record, but they still want a call. The practicing physician is kept on hold for ten minutes ($70 opportunity cost) only to read out loud from the record to the insurance doctor. Other times the rural doctor has to tell a big city cardiologist that he ordered a nuclear stress test on a female patient instead of a stress echo because the nearest facility that does stress echoes is 200 miles south on icy and snow-covered roads in the middle of January.

The economics of the medical practice require a certain productivity level just for survival, so the administrative duties are often given inadequate time, or no time at all, resulting in shorter patient visits just to capture a few moments to do the administrative work. There is still considerable unreimbursed provider overtime, leading to physician stress, disillusionment and burnout.

We should be paid for this work, as well as for reviewing results and maintaining our patients’ medical records over time and in between visits – all noble ambitions of the medical home.

We should also, of course, be paid for face-to-face visits with our patients.

But who should pay?

The problem with having private insurance companies, Medicare or Medicaid pay is that patients have little reason to consider value for money spent. It’s natural to be less concerned about how we spend someone else’s money, particularly if that money used to be ours, before the tax man or insurance company took it away from us!

I know I am only a country doctor, but I have seen many different systems of health care since I started medical school in 1974, so in my next installment I will outline A Country Doctor’s Proposal for Health Insurance Reform.

How Should Doctors Get Paid? – Part 3

Published April 26, 2014 How Should Doctors Get Paid? , Opinions 2 Comments

Should we be paid for outcomes?

This is often proposed, but I have trouble understanding it. Real outcomes are not blood pressure or blood sugar numbers; they are deaths, strokes, heart attacks, amputations, hospital-acquired infections and the like. In today’s medicine-as-manufacturing paradigm, such events are seen as preventable and punishable.

Ironically, the U.S. insurance industry has no trouble recognizing “Acts of God” or “force majeure” as events beyond human control in spheres other than healthcare.

There is too little discussion about patients’ free choice or responsibility. Both in medical malpractice cases and in the healthcare debate, it appears that it is the doctor’s fault if the patient doesn’t get well.

If my diabetic patient doesn’t follow my advice, I must not have tried hard enough, the logic goes, so I should be penalized with a smaller paycheck.

The dark side of such a system is that doctors might cull such patients from their practices in self defense and not accept new ones. I read about some practices not accepting new patients taking more than three medications. In the example I read, the explanation was not having time for complicated patients, but such a policy would also reduce the number of patients exposing the doctor to the risk of bad outcomes.

A few comparisons illustrate the dilemma of paying for outcomes:

Do firefighters not get paid if the house they’re dousing to the best of their ability still burns down?

Does the detective investigating a homicide not get a paycheck if the crime remains unsolved?

Does the military get less money if we lose a war?

Even if we were to accept and embrace outcomes-based reimbursement in health care, how would we measure outcomes?

We already know that an episode of care, say a hospitalization for heart failure or a COPD exacerbation can seem successful, but the 30-day readmission rate can cast doubt on that. First, of course, not all of that “outcome” is dependent on a single provider or even a group of providers, but involves ancillary staff, hospital resources and much more. This is one of the thoughts behind the Accountable Care Organization movement. Second, much of what happens in sickness and in health is not provider dependent at all. An unusually miserable weather pattern can make COPD relapse rates higher one month than the next, for example. What kind of bureaucracy would it take to create a payment scheme that factored in such things? And would our health care dollars really be better spent on such accounting efforts than on nursing staff levels or something else?

Other than short term outcomes for gallbladder surgeries, pneumonia hospitalizations and such discrete episodes of care, how would we measure “outcomes”, for example in primary care and disease prevention?

For pediatricians, would we follow their patients’ health into old age to determine how good their early care was? How about when patients switch doctors, often because of insurance coverage changes – who gets the credit or blame for future bad outcomes?

In short, I think outcomes-based reimbursement works only in a limited sector of healthcare. For primary care, and specialty care that spans over any length of time, we need to get back to basics in the form of Honest Pay for Honest Work.

And that will be the topic of my next installment…

A Fire In the Belly

Published April 26, 2014 Progress Notes Leave a Comment

Henry Halvorsen was in to see me the other day. 79 years old and usually brimming with optimism and vitality, he seemed subdued and frail. His weight loss and muscle weakness were obvious.

“Good to see you, it’s been a long haul”, I greeted him.

“Three surgeons, two CT scans, two hospital stays before they found out what was wrong with me, and then rehab and everything that happened there”, he said, exasperated.

It had started when I saw him in the office at the end of February. He had been in three weeks earlier with a flare-up of his recurring back problem. That had cleared up, but Henry was having some bowel trouble, mostly constipation but then sometimes a day of loose stools. He thought it was his muscle relaxant that caused his bowels to act up, but his bowels didn’t straighten out after he stopped his cyclobenzaprine.

He wasn’t running a temperature, but his appetite was off. He was definitely a little tender deep in his right lower quadrant, but there was no involuntary muscle guarding when I let go of the pressure with my hands. I ordered bloodwork and a CT scan and told him that even though his pain and irregular bowels had been there for a whole week, he could have a subacute appendicitis.

His white blood cell count came back mildly elevated, and his sedimentation rate was elevated at 40 mm. The wait for the CT seemed long, but he was feeling better. Then, the day before his scan was scheduled, he woke up with worse pain and severe diarrhea, so he went to the emergency room. The ER physician, Jack Morton, told him right away he was suspicious of appendicitis.

His blood count was a little higher, and his sedimentation rate was 50. His abdomen was mildly tender, as it had been in my office. The CT scan showed no definite abnormalities, but the appendix was not visible.

The surgeon who saw him didn’t feel there was quite enough reason to remove his appendix, and with intravenous fluids and bowel rest, Henry started feeling better. Another surgeon did a follow-up evaluation on the weekend and Henry was discharged home on the third day.

Two days later at one o’clock in the morning, he woke up with abdominal pain, followed by a very large, soft bowel movement. He had chills and felt nauseous. He called the ambulance and arrived at the emergency room actively vomiting.

Dr. Morton was on that night, too. He ordered the same bloodwork again and another CT scan. This time there were signs of a small bowel obstruction and free fluid in the abdomen. There were nonspecific inflammatory signs in the right lower quadrant but the appendix was not clearly identified.

The surgeon on duty that morning didn’t hesitate. In short order Henry was on the operating table and had his ruptured appendix removed and two Jackson-Pratt drains placed. He received intravenous antibiotics and spent the next few days mostly sleeping with a Foley catheter draining his urine and a nasogastric tube draining his stomach.

At the rehab, where he was receiving intravenous antibiotics, he developed urinary retention shortly after his catheter was removed. The nurses were unable to reinsert a catheter due to his enlarged and inflamed prostate. Henry had to be transported back to the hospital where his urologist managed to get a Foley in. Then, back at the rehab, he developed diarrhea again and was diagnosed with Clostridium Difficile enteritis, resulting in more, but different, antibiotics.

As we went over everything that had happened to him, he sighed and said “I’m lucky to be alive”.

I nodded and mused out loud. “It’s such a common disease, but it can present in so many ways”. I thought about the first CT scan and the first surgeon’s decision not to perform an unnecessary operation.

I told him when I was a resident in Sweden, surgeons used to talk a lot about what percentage of innocent appendices you needed to operate on in order not to miss any guilty ones. Between 15 and 40 percent of emergency appendectomies have been reported to reveal a normal appendix, and yet 20 percent of appendicitis cases are initially misdiagnosed.

By the time I did my residency here, my hospital had just installed its first CT scanner, and the diagnosis of appendicitis was no longer a purely clinical one. In some centers, the diagnostic accuracy of CT scanning is said to be as high as 98 percent. But, when the tests are inconclusive or, worse, wrong, it is still a hard judgement call whether to operate or not.

Older patients tend to have less typical symptoms and are diagnosed later in the course of the disease than younger patients. While most cases of appendicitis fulminate within 48 hours, in 2 percent of cases the duration is more than two weeks.

“I’m just happy I pulled through”, Henry said as he rose from his chair with obvious effort.

I shook his hand and answered, “I am, too, and we should all be humbled that the great trickster almost did it again.”

“I Hate Coming Here”

Published April 20, 2014 Progress Notes 5 Comments

It’s another Monday morning at the substance abuse clinic. It is my turn as the doctor in the black swivel chair in the corner office overlooking a half-vacant strip mall.

Today’s first inductee is a pregnant 22-year old with track marks on her forearms. Her obstetrician and caseworker at the Department of Human Services made her come. It is obvious she is less than thrilled.

“How long have you been doing opiates”, I ask with my fingers hovering over the keyboard. She tells her story, first in monosyllabic monotone, but as we move through the questions and she realizes I am not there to lecture her on anything, she warms up a little.

Because she is pregnant, she didn’t arrive here in withdrawal out of concern for the fetus. Her last use was the night before. I explain how to place the Subutex tablets under the tongue and avoid swallowing, so the medication is fully absorbed through the mucous membranes of her mouth. Then I fill out the prior authorization form for Medicaid. I make sure to put her due date on the form, so she will be approved until she delivers. Then I write the prescription, sign it and spell out my name and my special DEA number for opiate replacement prescriptions.

My next inductee is in a cold sweat. He is the same age as my own son. He snorted some Oxys and Ritalins Friday night. Today he has the shakes and the runs. He has no job, is in trouble with the law, and he has been here before, but was discharged because of repeated failed urine drug screens.

I document his COWS score, the degree of physical withdrawal he is in. He had been doing high doses, so I prescribe him 16 mg of Suboxone daily. I explain that since last time he was here, we have switched from tablets to strips that melt under your tongue the same way. He knows; he knows everything about opiates. Is he here again because of his circumstances, I wonder, more than from a deep desire to quit right now? His counselor’s notes in the computer record have a hint of skepticism in them.

“I hate coming here”, says my third patient for the morning. He is a foreman at a nearby factory, logging week number 178 in the program. He is on 2 mg per day. Going from 3 to 2 mg, he had a terrible time with both physical symptoms and cravings.

“I wish I didn’t have to be on this stuff. I want to be over this. I sit in the waiting room with these people who trade stories about what they have done, and I don’t want to hear it. I have a job, a family, and I hate having to come here for my lousy prescription, but I know I can’t keep my life together without it.”

Fourth up is a woman in her forties I haven’t seen before. She transferred in a week ago when Dr. Feiner sat in this chair. I recognize the woman’s name. She is a physician, who just lost her license a few months ago. She is stable on her dose. I write the prescription and she leaves quietly.

The next patient is a mother of two, who just had surgery for ovarian cancer. She is in obvious pain. We had talked last time about how Suboxone does help with pain, but it is not all that potent. She had told me then that she was more afraid of falling back into addiction than being in pain.

This time, she is tearful. Her cancer has already metastasized, and she speaks of what will happen to her two girls if she can’t be cured. She winces with pain, and I ask her again if she is sure she wants to stay in the program. Her husband already manages the Suboxone strips for her, and he could manage pain medications for her as well. But she knows that the naloxone in her Suboxone strips keeps her from feeling the same high that other opiates give.

“I am so grateful for what this program has done for me, that I don’t want to risk that, even for this”, she says and points to her abdomen. “Whatever time I have left..” She chokes, tears streaming down her cheeks, and blows her nose with tissue from the box on the corner of my desk. “Whatever time I have left, I want to be sober, and I want to be all there for my girls and for my husband. I don’t want to be strung out.”

“I hear you”, I say. But you are in pain, I can see that.” She nods.

“I’m going to increase your dose back up to our maximum. That will make some difference. But you may be helped by something like a fentanyl patch, that stays on for three days at a time…”

“Thanks, but this is fine”, she says as she takes her new prescription and strains to rise from the visitors’ chair by the window.

I rise and open the door for her. Then I close it and sit down quietly in my black swivel chair for a few minutes as I look out over the boarded-up windows of the empty storefronts across the parking lot.

I don’t hate coming here, as some of the patients do. It is sobering to think back on the ones who are forced to come here, the ones who come here when they can’t afford their drugs of choice, the ones who fight valiantly to get their lives back in order and the ones who have lost, or are about to lose, everything.

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