OP-ED

The Seduction of Primary Care

Hey there, big, smart, good-looking doctor….

Are you tired of being snubbed at all the parties?  Are you tired of those mean old specialists having all of the fun?

I have something for you, something that will make you smile.   Just come to me and see what I have for you.  Embrace me and I will take away all of the bad things in your life.  I am what you dream about.  I am what you want.  I am yours if you want me….

Seduce:   verb [ trans. ]

attract (someone) to a belief or into a course of action that is inadvisable or foolhardy : they should not be seduced into thinking that their success ruled out the possibility of a relapse. See note at tempt .

(From the dictionary on my Mac, which I don’t know how to cite).

If you ever go to a professional meeting for doctors, make sure you spend time on the exhibition floor.  What you see there will tell you a lot about our system and why it is in the shape it is.  Besides physician recruiters, EMR vendors, and drug company booths, the biggest contingent of booths is that of the ancillary service vendors.

“You can code this as CPT-XYZ and get $200 per procedure!”

“This is billable to Medicare under ICD-ABC.DE and it reimburses $300.  That’s a 90% margin for you!”

This is an especially strong temptation for primary care doctors, as our main source of income comes from the patient visit – something that is poorly reimbursed.  Just draw a few lab tests, do a few scans, do this, do that, and your income goes up dramatically.  The salespeople (usually attractive women, ironically) will give a passing nod to the medical rationale for these procedures, but the pitch is made on one thing: revenue.

Our practice has succeeded despite the fact that we don’t do a lot of procedures.  We are in a shrinking minority, and the monthly cash-flow is putting increasing pressure on us to think about “alternative sources of revenue.”  Most of my colleagues in private practice have labs, x-ray equipment, or do procedures.  Some do such medically vital services as hair removal.  I haven’t had the stomach to go that direction…yet.

Who’s at fault for this?  Is it the doctors, who are seeking profit over what’s best for the patient?  Is it the vendors, who find loopholes in the reimbursement structure to milk extra dollars out of the system?

If you leave meat on the floor, don’t be surprised when your dog eats it.

The payment for the E/M codes (the codes used to bill for doctor’s visits) are low and the payment for CPT codes (the codes used to bill for procedures) are high.  This is how our system is set up (with great thanks to the RUC) and it is one of the main reasons we spend so much money on healthcare.  We aren’t doing healthcare, we are doing sick care.  Healthcare is prevention, which takes face-to-face encounters with the patient.  It involves talking and listening, and talking and listening are not deemed valuable by our system.  We are paid to do, not to educate or listen.

It takes great resolve to resist this siren’s call.  A few years ago, we made a deal with one of the other practices in our building to buy a portion of their x-ray equipment.  It seemed to be a good way to make money off of something we do normally in practice.  But a few months into this deal, we realized two things:

  1. We weren’t ordering enough x-rays to be profitable.  We had established a mindset of ordering x-rays that minimized their use.  It was a nuisance to wait for the reading on an x-ray and it was inconvenient and costly to the patient, so we made most of our judgments based on something else: the physical exam.
  2. We were ordering a lot more x-rays than we had before.  Instead of trying to find reasons to not order x-rays, we were now financially motivated to order them.  So if someone hurt their ankle, we were much more likely to order one.  If someone had a chronic cough, we were much more likely to order a chest x-ray.  The change wasn’t that we were hungry for profit, it was just that we were suddenly 180 degrees from our previous mindset: we were trying to find medical justification to order more x-rays.  It was incredibly seductive.

We did back out of the deal, feeling that the care we gave wasn’t better and not liking the fact that we were losing money.  But would we have backed out if our practice wasn’t already financially stable?  We are a well-run practice that has been successful despite our non-reliance on procedures, but what of the other practices out there that aren’t so successful?

One of my favorite sayings is: your system is perfectly designed to yield the outcome you are currently getting. Nowhere is this more true than in healthcare.  We have set up a system that encourages consumption.  We pay doctors more to do more.  We pay doctors less to spend time with patients.  We want our doctors to do better care, but we pay them to do worse care.  We want to save money, but we reward those doctors who spend the most.

So why not change?  Why not pay more for E/M codes and less for CPT codes?  Yes, some doctors will abuse this system by running patients through their office and spending little time with them, but at least it will increase availability of doctors to see patients.  There will always be those who take advantage of any system; that shouldn’t stop change.

I went into medicine to take care of people, not spend their money.  Why can’t we have a system that doesn’t force me to decide between the two?

Rob Lamberts, MD, is a primary care physician practicing somewhere in the southeastern United States. He blogs regularly at Musings of a Distractible Mind, where this post first appeared. For some strange reason, he is often stopped by strangers on the street who mistake him for former Atlanta Braves star John Smoltz and ask “Hey, are you John Smoltz?” He is not John Smoltz. He is not a former major league baseball player. He is a primary care physician.

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mesothelioma doctorsPaoloPaoloHealth Insurance Fort MyersPeter Recent comment authors
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mesothelioma doctors
Guest

http://mesotheliomasurvival.i-medlab.com Thanks for that awesome posting. It saved MUCH time 🙂

Paolo
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Paolo

“Your concerns regarding incentives could be addressed by reimbursing patients who go to non-participating physicians at l0% below the standard Medicare allowance less coinsurance.”
Barry – I agree with your modified scenario 🙂 If insurance (private or public) offers fewer benefits/reimbursements for out-of-network providers, then there is an incentive to be in network. In commercial PPOs, out-of-network benefits are often 20% lower.
But if the payment amount is exactly the same (as in your example) and the timeliness of payment is the same (why would it be different?), it’s hard to see why any provider would elect to stay in network.

Barry Carol
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Barry Carol

Paolo – I disagree. Doctors who opt out of Medicare would have to collect their charges from patients directly and offer discounts from list on a case by case basis. Patients would have to submit a claim to Medicare to be reimbursed for the Medicare allowance less coinsurance though, as a courtesy, the doctor’s office might submit the claim on the patient’s behalf. Moreover, doctors with a practice consisting mostly of patients from the lower half of the income distribution might be hard pressed to collect from patients on a timely basis and could be much better off participating in… Read more »

Paolo
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Paolo

Barry – if any medical provider could bill Medicare for the same amount, there would be no incentive to be in Medicare’s network. Almost every provider will opt out. This would transform Medicare into a stipend system where all members get a fixed subsidy per procedure and then use it to shop around for medical services. If (and this is a big IF) this is what seniors want, I have no problem with it.

DeterminedMD
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DeterminedMD

Barry Carol is exactly right. And thank you to Dr Urbach for a supportive statement. I am here to be constructive. People do not realize that harsh actions are meant to bring about effective endpoints. Striking is outlandish, but, it would get attention of Washington as fast as saying the word “What?!” And believe me, we would not be striking for long. These are desparate times, and we owe it to patients and our equally invested colleagues to restore order and sanity. Again, to hell with the business model for this profession! Happy Thanksgiving. And to all going to airports,… Read more »

Dan Urbach, MD
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Dan Urbach, MD

Barry: your last post is exactly what I’m talking about. And if DeterminedMD is still reading this, thank you for a constructive comment. I agree wholeheartedly with you.

Nate
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Nate

Barry, All of that would take major legislative changes. Current law specifically sets the benefits and caps the plans and cost sharing that can be offered. I think insurers are very closed minded, they aren’t int he business of underwriting risk anymore. Your idea for a high deductible medicare option makes perfect sense, what about all the people with HSAs prior to 65 who suddently have to drop their consumer driven plan and switch to the most unconsumer plans of all. Not to mention if you have accumulated a sizeable chunk in your HSA you could never spend it down… Read more »

Barry Carol
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Barry Carol

I think the most practical potential solution for the balance billing issue within the Medicare patient population is to allow doctors who do not participate in Medicare to be considered what commercial insurers call out of network providers. While providers who accept Medicare might still have to accept its allowance as full payment, patients who choose to go to a doctor that doesn’t accept Medicare should be able to collect from Medicare what it would have paid if the doctor were in network. So, if the normal charge for a 99213, for example, is $100 and Medicare allows $50 and… Read more »

DeterminedMD
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DeterminedMD

Dr Lamberts: You end this post with this comment: “I went into medicine to take care of people, not spend their money. Why can’t we have a system that doesn’t force me to decide between the two?” I do not think they can be mutually exclusive, because unless you want to take a vow of poverty and treat people for the sake of personal satisfaction alone, you have to be paid for providing a service, albeit one that it is hard to put a specific monetary value on it. So it comes down to the basic premise of any transaction:… Read more »

Margalit Gur-Arie
Guest

“Besides, with balance billing, as I’ve said before, there would be a huge market for supplemental insurance, who would most assuredly negotiate usual-and-customary prices.”
Dr. Urbach, isn’t this just a simple reductions of benefits for Medicare people?
The supplemental carrier will be the one deciding how much you get paid.
This doesn’t look or sound like the balance billing Dr. Lamberts had in mind, where people have to bargain for discounts or beg for charity when they go to the doctor (or perhaps bring in some homegrown squash).

Barry Carol
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Barry Carol

Dan – For the last several years, CMS has means tested Part B services by requiring beneficiaries who earn more than $85K (single) or $170K (couple) to pay more than the standard Part B premium of $110.50 per month for those aging into Medicare this year. That standard $110.50 is intended to cover 25% of program costs which implies that the actuarial value of Part B services is currently $442 per month ($110.50/ 0.25). At the high end, both singles and couples who earn above $428K must pay $353.60 per month each for their Part B services or 80% of… Read more »

Rob
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Determined: You miss the point of this post. I am not complaining that the system doesn’t favor physicians in a business model. If I was doing it simply as a business, I would just rack up as many procedure codes as is possible. The business model is not hard, it is just bad. It is bad because it dooms the system and it penalizes those of us who want to practice business HONESTLY. The system encourages a business model that is harmful to its own survival. By the way, I do not write for THCB. I write for my own… Read more »

Paolo
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Paolo

Dan – I get your point. I think a reasonable solution/compromise would be to allow some premium MA plans to contract with doctors who opt out of Medicare and pay them above Medicare rates. I don’t know if this requires a change of statutes, regulations, or business practices. But it’s the only way to keep contractual rate protections for all Medicare members, while allowing a few wealthier members to use some of their Medicare dollars to pay for better services. I think this is much more likely to happen than balance billing.

Dan Urbach, MD
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Dan Urbach, MD

Paolo: I’ve opted out of Medicare. So Medicare Advantage is not applicable to my practice.

Paolo
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Paolo

Dan – I am not a benefits administrator, nor do I work in the medical sector. I’m just a consumer who knows by experience to never go out of network.
I infer from you lack of response that you don’t take any Medicare Advantage plan. If there really were a huge market for seniors who want to pay extra to access premium doctors, there would be some premium MA plan by now that addresses that market.
In any case, we all know that nothing is going to happen in this area unless the majority of seniors want it.