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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