September 12, 2011
Doctors Speak Out On Fixing Health Care
By Michael D. Shaw
This week’s article is based on a revolutionary concept: People who actually work in health care should be given a voice in health care reform. Many of us are tired of listening to the pontifications of various wonks, whose main claim to fame is that they are politically connected, or look good on television.
I recently spoke with Washington, DC based Matthew Mintz, MD. Dr. Mintz is a board-certified general internist with The GW Medical Faculty Associates and is an associate professor of medicine with The George Washington University. Mintz’s clinical interests include asthma, emphysema (COPD), obesity, and diabetes.
Dr. Mintz has published numerous journal articles, as well as the book Disorders of the Respiratory Tract: Common Challenges in Primary Care. He also has some strong opinions on health care reform.
We first dealt with the issue of controlling costs. He challenges us to focus on the parameters that truly affect cost, rather than trust politically opportune sound bites…
If you’re a left-wing Democrat and believe one hundred percent in the Affordable Health Care Act (Obamacare) and its principal mechanism of saving money via accountable care organizations, even at maximum success this is not going to be enough to control costs.
Likewise, if you’re a diehard right-wing Republican, and believe that we can improve quality and decrease costs by putting decisions in the hands of the patient, letting them make educated responses, and increase competition, even at maximum success this too will not be enough to control costs.
That’s because neither approach addresses the main factor driving up health care costs—and that’s technology.
We’ve got great new drugs, new surgical techniques, and wonderful new devices, so naturally everybody wants them. The problem is, we can’t afford to pay for them. Once we start addressing this issue, we might be able to make some progress.
I then brought up the matter of out-of-control malpractice litigation, and thus the notion of defensive medicine—done to avoid such lawsuits. Mintz acknowledged that while it is difficult to determine the full extent of of defensive medicine, it should probably rank in second place as a factor that drives up costs. He then made it personal.
Here’s a perfect example of how the system is failing. If a patient comes in with a headache and demands an MRI, I could spend five minutes and give them the referral, or I could spend 30 minutes trying to talk them out of it.
Either way, I get reimbursed the same amount, because I’m getting paid for a Code 99213. I’m not paid for my time in counseling patients. Clearly, my incentive is to give the patient what he wants, even though I know that it might not be necessary.
The system is set up in such a way that there is no incentive for doing the right thing, but all the incentives for doing the wrong thing. Is it any wonder that we have poor quality and high cost?
Related to this is the perverse idea in American health care (unlike virtually all other systems) that procedural medicine is somehow superior to cognitive medicine. In Canada, for example, primary care doctors are usually the highest paid physicians, not the lowest paid as in the US. But, in our disease care model, procedures earn much more than primary care office visits.
At first, Mintz objected to the word “superior,” but I reminded him of one unassailable fact: Money is the most objective thing in the world because it provides a numerical rating on the value society places on a product or service. There are no exceptions to this, despite all sorts of posturing and rationalization.
In our system, procedural medicine is superior to cognitive medicine because it gets bigger reimbursements. Mintz observes docs leaving primary care, and medical students avoiding the field. He points out that primary care physicians, despite being the dominant members of the profession, are disproportionately poorly represented on the Relative Value Scale Update Committee (RUC) for reimbursement advice.
Evidently, six doctors from Georgia agree with him. Last week, they filed suit in U.S. District Court, claiming that the RUC violates the Federal Advisory Committee Act’s requirements for representation, transparency, and methodological rigor. The plaintiffs assert that the RUC “has systematically overvalued many specialty procedures while undervaluing primary care.” The plaintiffs want a federal judge to suspend the RUC process until federal agencies comply with FACA rules.
One of the plaintiffs, Paul Fischer, MD, noted that:
We have too many specialists doing too many unnecessary procedures and the price that we pay doctors has been fixed by this secret little committee of the American Medical Association. That is illegal. Let’s come up with a better way of pricing physician services more in line with the value they provide to the society.
The plaintiffs first tried going through channels, including the AMA and the American Academy of Family Physicians. Fischer says, “They are part of the problem. When they were unwilling to do anything I decided to go it alone.”
While I’m not at all surprised by trade guilds acting against the best interests of their members, I am slightly taken aback—and encouraged—that doctors are finally trying to fix the problem from within. May their movement grow.