The practice of medicine was corrupted long ago by fee for service, which links a physicians compensation to the volume of care prescribed. More treatments/prescriptions/tests, more income.

We therefore waste 40% of all the money we spend on health care, an unconscionable amount that the Institute of Medicine concludes adds nothing to our well-being.

We do not yet know what the right solution will be, but mushrooming costs and the ACA will encourage better answers than the ineffective, inefficient and cruel approach that has cost Americans and America so much.

My doctor consulted with an ER doctor after a finding of DVT and did not recommend that I immediately go to the nearest ER that had an ultrasound tech on duty, which my hospital did not. He delayed the ultrasound request the next day until the clot passed above my leg, necessitating an MRI, but when I wanted to go somewhere other than an affiliated hospital, his office balked and basically quit even trying to get the MRI. Meanwhile, I could have died. Fortunately, I didn’t, but the whole experience made it very clear to me that these incentive payments have to stop.

Do you live in this country? Have you been traveling to another galaxy? Everything, EVERYTHING is now subverted to a market place commodity including education and, yes, medicine.
We are relentlessly concerned with how much doctors make and how productive they are. That’s like focusing on whether the goose is working hard enough when we check the price of fois gras. Why does no one ever look at the VAST waste and excess found in the insurance industry and the pharmaceutical industry? Check out the checks those execs and managers and middle managers and lwer middle managers are taking home. More than enough to provide Cadillac care for every man, woman and child in North America. Docs work long hours and get paid well enough, mostly. But the average Doc, for the time, the educational expense and the sacrifice, is doing it for love, not for bank.
Angry MD here.

I applaud the author. I am board certified in Family Medicine and Geriatric Medicine and I manage a 10 provider practice in Michigan. Everyday-literally everyday-my practice is forced to make concessions to comply with standard based metrics that are often not in the best interest of patients. Although this is a strong word, we are being extorted to acquiesce to demands by insurers and by extension our own complicit physician organizations.

I am a recent medical director of the largest physician organization in Michigan so my perspective is not that of non-business savvy or disgruntled primary care doctor or PCP. It is based on deep executive experience on how the system works. If patients understood the economic pressure brought to bare upon their doctors to comply against their medical judgement to avoid severe economic penalties they would not stand for it. In primary care we must literally choose between economic survival and true patient advocacy.

This is not why we sacrificed half of our adult lives to become physicians. Health care delivery has devolved into an aberration that saddens most physicians today. The ACA did not create this mess but it is accelerating a health delivery system off the rails for two decades. The saddest thing of all is how many of my colleagues in their forties and fifties are looking for “exit strategies”–how pitiful is that?

This is very true, and great that it is finally being pointed out that many doctors today are in an ethical bind where they can not put the patient’s well being first. However you missed the biggest factor: the employment of doctors by hospitals, where their very employment itself is dependent upon pleasing their for profit masters. You cannot serve two masters, and if your employer demands that you only can refer to other doctors and testing sites within your own hospital, and you cannot advise against a surgery in a supposed second opinion because another employed surgeon at your hospital has recommended it and it represents many thousand dollars to the hospital bottom line, then you must go against your own best judgement for your patient just in order to keep your job. So forget the insurance companies, the real villain is the huge government incentives for hospitals to buy up all the doctors and thus assure themselves of high downstream revenues from excessive testing and unnecessary surgeries.

I am so happy that my medical career is over. My last 8 years I worked as an OB-GYN for The Choctaw Nation of Oklahoma. Those were the best years of a 40 year career because I did not have to deal with some of the insurance issues mentioned in the article. I was salaried and my pay remained the same whether I performed 5 surgeries a week or none at all. There were no incentives to do or not do. Each patient was an individual and each had a treatment plan tailored to her needs.
I was on the receiving end of care this past week. A dermatologist that I saw diagnosed many precancerous small lesions on my face and neck. She treated 7 of these with liquid nitrogen. Why treat only 7 when she found about 18? Because Medicare will only pay for 7 lesions at a time! It would have taken her about 5 more minutes to treat the rest but she would not have been paid for it. Had she been salaried I would not have to make two more trips to her office.

Alone among industrialized nations, we have set up a medical care system in which the middleman (aka the insurance company) skims a profit off the backs of doctors and patients alike. The idea of middlemen is by no means inherently wicked–their extremely helpful in buying and selling homes, or in managing one’s savings investments–two areas where matters are so complex it’s hard for most ordinary people to figure things out on their own. And lawyers are necessary middlemen as well–there may be too many of them, but most of us need them to navigate the complexity of the law.

Health insurance companies, with their parade of pamphlets and emails on wellness and health issues, are now on the offense, busily advertising themselves to the public as a necessary part of healthcare. Unfortunately, the fact that Americans are terrified of government taking away their “freedom of choice” with medical care, but are oblivious to the ways in which insurance companies have already stripped them of those freedoms, will keep us stuck with this mess for a long time to come.

Here in Norway family doctors have a given target number of patients. Doctors with insufficient patients are available for patients to choose. They are paid for being available to their patients and not by the services they perform. They have no incentives to perform necessary procedures or to sell a particular drug or therapy.

A market based system is good for many areas of the economy, but health and human well-being is not a good ‘market’.

A single-payer system, is far more efficient and less prone to corruption.

The authors point out a truth – practice guidelines do not always best fit the needs of particular patients. So, we should improve policies and practices for making exceptions to guidelines, make them better known and less onerus to physicians and patients. But, as David RR says below, let’s not throw the baby out with the bathwater.

At the heart of the author’s argument is the presumption that physicians will be influenced by financial incentives to the detriment of their patients. The question is how many physicians will be influenced by such incentives and how many patients will not get the best care – compared to the prevailing financial incentives?

The health care system has been and is still trying various incentive approaches to offset the ills of the prevailing incentive scheme. That has been and still is by far the strongest incentive that affects most physicians and most care – to pay physicians for each service provided, so they have an incentive to provide more, and to pay them much more when they deliver more expensive treatments, surgeries and in the case of oncology, for example, more expensive drugs. It has been well documented in many studies and in two historic reports by the Institute of Medicine that paying for volume of service results in a lot of over treatment, too many complications of care and too many deaths. It also results in too little preventive and primary care, because those are not as well reimbursed.
Which poses a greater risk?

The incentive to exclude people who might get sick, along with an improved ability to predict who might get sick, means that private insurance will not work for a large segment of the population. Very few people can afford the cost of a significant medical procedure. Do we just let people die? I personally am wasting a great deal of time trying to get an insurance company to pay for a procedure that is clearly covered. It’s a huge waste of resources for patients and doctors, and adds to the overhead of insurance companies (but still a profitable tactic since most people don’t fight back). Countries with single payer have better results at about 1/2 the cost. How can anyone defend a system that costs twice as much, produces worse results, and merely transfers money from patients to a third party industry that doesn’t treat or cure anyone?

This is a valid concern, and was an equally valid concern under the old fee-for-service system. Doctors made more money by performing more procedures. There is even software they could buy to maximize billing codes for a given patient visit. Such software (designed to increase costs without improving care) should not exist and is a symptom of a broken system.

The good news is, all the concerns expressed in the article can, indeed must be addressed. Now is the time to do it. The first attempts at pay-for-outcome were bound to be imperfect. The author and all doctors should be contributing to payment reform. Pay for performance gives us a framework for aligning financial incentives (what’s best for the doctor) and outcomes (what’s best for the patient). That’s where our efforts need to be right now.

It’s no secret that health insurance companies make their money by rationing access, prevention, diagnostics, therapy and palliative care. This rationing results in sickness, death, dying and bankruptsy of the patients. Insurance companies will therefore never reveal their outcomes, or compete capitalistically based on the quality of care delivered to their patients because we might find out that in age and disease matched patients Humana patients are sicker and die sooner than United or Blue Shield Blue cross patients due to their rationing of care.

Instead, insurance companies compete based on billboards and magazine ads which show smiling doctors in white coats who claim to be the ‘best’. What a scam, what a fraud, what a crime.

Over here in the UK, we have the National Health Service, which is often accused of rationing health care. What is being described in this article is a form of rationing. The difference is that in the UK the guidelines governing the use of various treatments and drugs are made by a quango, the National Institute for Clinical Excellence (NICE), and are published on their website. The membership of the committees that create these guidelines is a matter of public record. The process is therefore transparent and can be scrutinized by the public. This scrutiny puts pressure on NICE and on its governmental masters, and occasionally results in changes in the guidelines if they are seen as unduly harsh.

On the other hand, the extensive rationing of health care by insurance companies in the US is driven largely by commercial considerations, and is covert. Congress should force insurance companies to publicise the kind of information described in this article, and should also make hospitals publish the costs and profits associated their operations. This would allow Americans to exert some control over their health care systems, and would highlight the areas most in need of improvement.

To augment Victor Borge:
“I pledge seven-lesions to the flag ….”?

What’s that, you say? Overpaid MBAs and political hacks who could never do your job are now dictating every last detail of how you do your job? Sorry to hear it, and welcome to the party.

Sincerely,
Teachers and Professors

What I find disturbing is penalizing patients who go out of network for a second opinion, and potentially, better treatment elsewhere. If one lives in a community with substandard physicians, such penalties put the patient and their families at extreme risk. Not every doctor graduated in the top 10% of his/her medical school’s graduating class. And some doctors went into the profession for the wrong reason – to make money above all. This reward by insurance to punish doctors monetarily for allowing patients to go out of network just makes me sick, as does paying doctors bonuses for keeping their patient in line. Something very unethical here. Might as well throw out the Hippocratic oath.

There needs to be a law to protect the public and the physicians from the insurance industry. Especially since it is the private insurance industry that has only one interest – maximizing it’s profits at the expense of sound physician practice and individual patient health.

I have a first hand story to share. My husband has stage IV pancreatic cancer. He is being treated at a prestigious hospital in Southern Minnesota. The incident occurred a couple of weeks ago so it is still fresh in our mind.

The oncologist conducted his consult while my husband was in the middle of his chemo treatment (nice way to collect a two for one). During the consult, the oncologist excused himself and said he had to attend a Finance meeting. He said he would return to finish the consult. When the oncologist returned, he started to wave a printout and appeared smitten with himself. He said that the printout contained information about whether he met “the numbers”. That is to say, he was “above the yellow line” highlighted on the printout. He said that the clinic monitors the $$$ spent on patients by diagnosis/cancer type. I assume that if the oncologist’s numbers were “below the yellow line” that he would have to cut back on treatment in order to meet the institution goals for dollars associated with recommended treatment.

Needless to say, we were appalled by his candor….and shocked as we began to realize the consequences that this sort of heavy handed monitoring and the consequences that it may have on my husband’s care. It is hard to comprehend that this is the kind of treatment that is given by the “Best Hospital” in the country.

“…if your employer demands that you only can refer to other doctors and testing sites within your own hospital, and you cannot advise against a surgery in a supposed second opinion because another employed surgeon at your hospital has recommended it and it represents many thousand dollars to the hospital bottom line, then you must go against your own best judgement for your patient just in order to keep your job.”

Don’t most working people “serve two masters,” as you put it? My mechanic has a financial incentive to exaggerate the extent of repairs My landscaper has an incentive to damage my trees so I’ll have to replant in the spring. Farmers and grocers have an incentive to short my quart of milk by an amount I’m not likely to notice. This article at least helps identify the incentives, but doesn’t excuse physicians for violating the kind of trust that we put in people from all walks of life during the course of a normal day.

As long as we view health care as a business, rather than a right, we will face these problems. The fact that everything in our country is considered a marketable, money-making commodity leads to this kind of mess. My European friends are baffled by our for-profit, for-insurance companies health care system. I am, too.

Someone should do an instruction manual for patients, given all these ongoing developments, about how to interview prospective new doctors (which questions would uncover their incentives so at least you’d know what you’re dealing with?), how to research alternative treatments or less drastic treatments (in case your doctor is being incentivized to present only one), how to make sure your hospital bill really will be paid or insist that the only providers brought in to consult while you’re there are on your insurance plan, etc. Patients really need to be strong advocates for themselves, but most probably have no clue how to start.

Excellent article. I would just add the power that pharmaceutical companies have in controlling treatments and medical knowledge. Hardly any doctors are aware of the nutritional supplements that can take the place of or mitigate the adverse effects of many medications, to the benefit of patients. The average doctor when asked about these alternatives will simply reply “don’t take that”, or “there’s no proof of that”, when actually they are just not aware of the studies. One can’t really blame them with all of the pressures on them, and pharma seeing to it that they remain in the dark.

We physicians are often pushed by non-medical factors, and that’s not necessarily a bad thing. When caring for patients in the hospital, doctors have a financial incentive to keep patients in for longer, while hospitals have a financial incentive to discharge sooner. This push and pull often results in a happy medium. The key is to coerce physicians into performing quality medicine. The article alludes to blood pressure control potentially leading to falls in the elderly. An appropriate blood pressure target depends on the particular patient’s age and coexisting diseases. Rather than fighting against the existence of quality measures, we physicians need to improve the measures’ quality.

I have had experience with exactly this phenomenon. I suffer from intractable migraine – I have a history of status migranosis or migraine lasting more than 72 hours. In addition, I have cycles of migraine over the course of years when the migraines wax and wane.

After a couple of years of relatively low migraine activity, my migraines started up again. My doctor refused to prescribe the one drug we knew was capable of treating the migraine because “it wasn’t in the formulary.” It actually was, but at a much higher co-pay and with the instructions to try another medication first. I had to suffer through a seven-day migraine to finally get the medication that would actually work on future ones. In addition, she wouldn’t refer me to a neurologist. I finally left her care for this and other reasons.

When I started with the neurologist, he wanted to start me on a preventative medication but the insurance company wouldn’t approve it because we hadn’t tried several other treatments (that had been proven to not work and were more dangerous but cheaper) first. We opted to wait as the migraine frequency wasn’t that bad. A year later, when the migraines were occurring up to 30 days in a row and up to 2 weeks apart, the insurance company had dropped its requirements and I could start using the medication.

And that is only one component of my health care. Without insurance, I’d be bankrupt. But I have to watch my insurance closely to make sure I get all the benefits I pay for.

Treating all patients the same makes for bad medicine and preventable bad outcomes. Most of the accumulating medical knowledge is of value precisely because it uncovers crucial differences between patients and their maladies that lead to breakthroughs in disease management and the avoidance of unneeded toxicity. Not to mention that valuing the differences between patients based on their preferences, values, social supports etc. is a precious and essential part of medicine. The elimination of medical common sense by administrators who for the most part know nothing of medicine so that they can cut medical costs necessarily leads to suboptimal outcomes for anyone who is not “the average” patient. The assumption of sameness in medical care is dangerous and amounts to selling everyone the same shoe size based on the notion of the average sized foot. It runs counter to common sense and to scientific evidence.

In the private insurance industry, cutting costs translates into profits for the company and unconscionably large bonuses for the plan administrators based on guidelines that treat everyone the same, reduce access to care, and pretend to be the “final word” on what an evolving understanding about disease and treatment. Incentivizing and penalizing physicians in a system run by administrators represents the end of medicine, not a beginning. The fee-for-service systems may have perverse incentives, but I’m afraid what we are moving towards will be far worse.

kommonsentsjane