Physicians

How Doctors Are Trapped, Part II

Of all the people in the health care system, none is more central than the physician. Fundamental reform that lowers costs, raises quality and improves access to care is almost inconceivable without physicians leading and directing the changes. Yet of all the actors in modern health care, none are more trapped than our nation’s doctors. Let’s consider just a few of the ways your doctor is constrained, unlike any other professional you deal with.

No Telephone. Sometime in the early part of the last century, all the other professionals in our society — lawyers, accountants, architects, engineers, etc. — discovered the telephone. It’s a handy device. Ideal for communicating with clients. Yet even today I find that I can rarely talk to a doctor by phone. Why is that?

The short answer is: Medicare doesn’t pay for telephone consultations. Medicare has a list of about 7,500 tasks it pays physicians to perform. And talking by phone isn’t on the list — at least in a way that makes it practical. Private insurance tends to pay the way Medicare pays. So do most employers.

At a time when doctors feel like they are being squeezed on their fees from every direction by third-party payers, most become very focused on which activities are billable and which are not. And most are going to try to minimize their non-billable time.

No E-Mail. Sometime toward the end of the last century, all the other professionals discovered e-mail. In some ways it’s even better than the phone. Everybody e-mails everybody these days. Even the corner liquor store e-mails me when they have a bottle of wine they know I will like. Everybody e-mails everybody — except doctors.

Why is that? Again, the short answer is: this is another task that’s not on Medicare’s price list — at least not in any way that makes e-mailing practical. Since Medicare doesn’t pay, all the private insurers who piggyback on Medicare’s payment system follow suit.

The fact that patients cannot conveniently consult with physicians leads to two bad consequences. First, the unnecessary office visitors (say, patients who have a cold) expect at least a prescription in return for their investment of waiting time, and all too often the drug will be an antibiotic that won’t help their cold. Were e-mail or telephone consultations possible, the physician might recommend an over-the-counter remedy, thus avoiding the cost of waiting for the patient and the cost of degrading the effectiveness of antibiotics for society as a whole.

At the same time, rationing by waiting at the doctor’s office imposes disproportionate costs on chronic patients who need more contact with physicians. This might be one reason why so many are not getting what they most need from primary care physicians and what is most likely to prevent more costly problems later on: prescription drugs.

The ability to consult with doctors by phone or e-mail could be a boon to chronic care. Face-to-face meetings with physicians would be less frequent, especially if patients learned how to monitor their own conditions and manage their own care.

Lack of Electronic Medical Records. The computer is ubiquitous in our society and many believe that electronic medical record (EMR) systems have the capacity to improve quality and greatly reduce medical errors. Yet, only about half of physicians have such systems and most of those are not connected to other physicians’ offices and hospitals, do not allow electronic prescribing, etc. The same is true for hospitals. One study concluded that “information systems in more than 90 percent of U.S. hospitals do not even meet the requirement for a basic electronic-records system.” Why are most medical records still stored on paper? Again, the short answer is this: There is no financial incentive to do otherwise.

EMRs may improve quality, but in the third-party-payer system, doctors do not compete for patients based on quality. EMRs may be a boon for patient convenience — especially in transferring information from doctor to doctor, but physicians don’t get paid for increasing patient convenience.

The Kaiser Exception. There is one health plan that does make extensive use of the telephone, e-mail and electronic medical records (EMRs). The insurer is California-based Kaiser Permanente. Unlike most private insurers, Kaiser doesn’t pay for care the way Medicare pays. Instead, it employs most of its doctors in a health maintenance organization (HMO) model. Because the plan is responsible for all the health care costs of its enrollees, it has an incentive to make use of technology that reduces overall cost. Telephone, e-mail and EMRs are among these. HMOs have their own perverse incentives, however, and some of Kaiser’s less attractive outcomes have been chronicled by Harvard Business School Professor Regina Herzlinger.

Ironically, the tax law favors the HMO form of delivery (because all premiums an employer pays to Kaiser are paid with pre-tax dollars) and has traditionally discriminated against individual self-insurance. However, the HMO doctor is no more free than the fee-for-service doctor. Both are trapped — although in different systems.

Inadequate Advice About Drugs and Other Therapies. Why do doctors so oftenprescribe brand-name drugs and fail to tell patients about generic, therapeutic, and over-the-counter substitutes? Why do they typically not know the price of the drugs they prescribe or the costs of alternatives? Even when they are vaguely aware of cost differences, why does your doctor not know where you can get the best price in your area for the drug she prescribes? Once again, the short answer is: They do not get paid to know these things. Knowing the current best price, knowing where the patient can obtain that price, and knowing the prices and availabilities of all of the alternatives is demanding and time consuming. For the doctor, it is time that is not compensated.

Inadequate Patient Education. Numerous studies have shown that chronic patients can often manage their own care, with lower costs and as good or better health outcomes than with traditional care. Diabetics, for example, can monitor their own glucose levels, alter their medications when needed, and reduce the number of trips to the emergency room (ER). Similarly, asthmatics can monitor their peak airflows, adjust their medications and also reduce ER visits.

To take full advantage of these opportunities, however, patients need training that they rarely receive. ER doctors could save themselves and future doctors the necessity of a lot of future ER work if they took the time to educate the mother of a diabetic or asthmatic child about how to monitor and manage the child’s health care. But time spent on such education is not billable.

Escaping the Trap. What is the common denominator for all of these problems? Unlike other professionals, doctors are not free to repackage and reprice their services in customer pleasing ways. The way their services are packaged is dictated by third-party-payer bureaucracies. The prices they are paid are similarly dictated. Doctors are the least free of any professional we deal with. Yet these un-free actors are directing one-fifth of all consumer spending!

John C. Goodman, PhD, is president and CEO of the National Center for Policy Analysis. He is also the Kellye Wright Fellow in health care. His Health Policy Blog is considered among the top conservative health care blogs where health care problems are discussed by top health policy experts from all sides of the political spectrum.

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Peter1Mark NPeter@selfpaymri.comVikram Crbar Recent comment authors
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Vikram C
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Vikram C

More good points from Peter1. So lets map it out in graph form ——————————————————————- Overhead costs are high | Blame revenue method | Profess that you care for customers but revenue method stops | Customers don’t seem to care for this service when selecting physician | Now it seems they are not even needed. Nurses can educate

Peter1
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Peter1

Dispensing medical advice involves diagnosing the patient, diagnosing the patient depends on seeing them. Dispensing legal advice does not depend on seeing the client. It’s money foolish to pay a doc to educate patients – that’s what nurses are for. If I want a script refilled I just have the pharmacist call/fax/email the doc’s office, works every time for simple refills. “Why are most medical records still stored on paper? Again, the short answer is this: There is no financial incentive to do otherwise.” Ever tried going to court with an EMR? Want more use of EMRs (at lower cost)… Read more »

Vikram C
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Vikram C

Peter, You are edging closer to where I am coming from and that customers are missing in all this communication and my ire is some fake tears are being shed in their name. When end customer is unable to defend his/her best interest for whatever reason, no one else will defend theirs. I see limited customer movements based on sevice quality that matters. If the customers did show mobility and moved based on service quality, doctors would provide these additional freebies considering them cost of business. After all, carpet or receiptionist or decor etc do not have CPT code, yet… Read more »

Peter@selfpaymri.com
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Fortunately, or unfortunately, providers found a formula that worked. To scale in a FFS world, your metrics are exam rooms, providers, added hours, more access, better contracts, and generally “more” rather than “better” (all add expenses and income). Everyone encourages it – heck, Medicare is now paying well over $100 for a 99214 now in most markets – a 40% increase in the last ten years. Most docs within 10 years of retirement will not change – most PCPs are making more now than they ever have (Receivable are clean, third party billing is a piece of cake, and now… Read more »

Vikram C
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Vikram C

So now we narrowed down to office overhead as root cause of problem. Revenue method is irrelevant because phone advice will bring it’s own issues. Also Peter’s post seem to indicate, key issue for phone advice is FFS versus Managed care. Now we can latch onto important question of why physician office overhead costs are high and what are they doing to reduce it. Also there is important question of how not providing adequate time to patients is impacting physician revenue. If revenue is really not being impacted and office are able to build up large number of active charts… Read more »

Peter@selfpaymri.com
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Good analogy with other professionals although the client load for these other folks are probably 1/20 that of an established PCP. FFS “rewards” the building of a very large patient base, always adding new patients, lots of payor participation, plans, in-house ancillary distractions, more providers, etc. I don’t think 1,500+ active charts for an established PCP is uncommon. Besides the lack of reimbursement for non face-to-face encounters, most time not in the exam room is typically spent on messaging, incoming note / result review, and “fire” extinguishing. Of my PCP friends that are dedicated to Medicare Managed Care payors –… Read more »

Vikram C
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Vikram C

Good points but straw man arguments. Let’s approach this in different way. Doctors are there to treat and help improve help health. Their billing offices are there to ensure that costs are covered and some profit is made through judicious billing practices. I don’t see any docto worrying about diagnosis or CPT code when they see patient. If the costs is covered, then what is possible reason for doctor to not to call patients or train a diabetic child’s mother? The main reason as I see is that their lifestyle will be impacted and there is nothing to be lost… Read more »

Mark N
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Mark N

If the costs is covered, then what is possible reason for doctor to not to call patients or train a diabetic child’s mother? That’s exactly the point…. The costs AREN’T covered. The only thing I do that I actually get paid for is see patients in the office. Everything else–phone calls, reviewing results, filling out forms, processing refills, emails, etc. etc is free unpaid work. If I turn 25% of my office visits into unpaid telephone calls or emails, then how am I supposed to pay the office overhead or make a living? Keep in mind the overhead is already… Read more »

rbar
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rbar

I am always surprised when some of JG’s writings actually make sense (call it the – very rare – Charles Krauthammer phenomenon). But: ER doctors could save themselves and future doctors the necessity of a lot of future ER work if they took the time to educate the mother of a diabetic or asthmatic child about how to monitor and manage the child’s health care. But time spent on such education is not billable. That’s only in part right. Docs can bill for time spent in counseling, to some extent. The problem is that ER physicians are, IMHO, rarely the… Read more »

Dr. Gene
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Dr. Gene

You make it sound as if all physicians are victims when in fact this is not the case. Having practiced in California during the rise of managed care it has always been apparent to most of us that the Healthcare system never rewarded physicians for” thinking.” Our entire system of reimbursement is predicated on doing procedures. People have never been rewarded for ongoing care. In the “good old days” an internist or family physician made money doing EKG’s, Lab tests, or x-rys in his office. Those days are gone. If we are to get serious about health reform we need… Read more »

Dr. Mike
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Dr. Mike

It seems easy for some to ignore the fact that most of the other professionals mentioned in the article don’t get paid directly for their use of communication devices and technology either. The incentive comes in a form that is increasingly off limits to physicians – their customers are able to reward or punish them according to the effectiveness of the overall service or experience provided. There are attempts to do this in an artificial and ultimately ineffective way (press ganey) but the most effective way, the way the rest of the professional world works, is off limits. I routinely… Read more »

BobbyG
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Oops. Forgot to change my satirical screen name (which nonetheless linked to me, but to one of my joke images).

SantorAway
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“To take full advantage of these opportunities, however, patients need training that they rarely receive. ER doctors could save themselves and future doctors the necessity of a lot of future ER work if they took the time to educate the mother of a diabetic or asthmatic child about how to monitor and manage the child’s health care. But time spent on such education is not billable.” ___ Agree. See “Medicine in Denial” “The course of a chronic disease depends on numerous variables, none of which the practitioner personally experiences, most of which the practitioner does not control and some of… Read more »