Excellent diagnosis, doc

    In response to the New York Times' “The $2.7 Trillion Medical Bill” (“Paying Till It Hurts” series, front page, June 2,)

    Kenneth Prager, a professor of clinical medicine at Columbia College of Physicians and Surgeons, wrote the following short Letter to the Editor, which was published June 3 along with several others:

    I suspect that if physicians were salaried there would be a substantial decrease in the number of medical procedures performed, including colonoscopies. Money has an insidious way of biasing medical judgment. When physicians profit from every procedure, it is too easy for some to justify it as in the patient’s best interest even when sound clinical judgment argues the contrary.

    Second: There is a yawning and unjustifiable gap between payment for procedures and consultations. When I spend an hour to an hour-and-a-half with a patient who brings a stack of medical records and many imaging studies, I must often answer to Medicare for charging its highest consultation fee, which is but a fraction of the amount allowed for endoscopy.

    Third: Overcoming an American culture that believes that more medical testing is better is a daunting challenge.

    There is so much that is wrong with the byzantine and arbitrary way our doctors and hospitals are paid, and so many powerful entrenched interests arguing for the status quo, that it’s easy to be pessimistic about meaningful reform.

    Englewood, N.J., June 2, 2013


    Institutions like the Cleveland Clinic acknowledge that having salaried physicians improves patient care and cuts costs. Top rated hospitals like Johns Hopkins and Massachusetts general have salaried physicians. The pushback against having physician income paid as salary comes from the idea that physians should be independent operators like lawyers and businessmen. Income should be equal to output if a person works hard, they should earn more. That concept will be hard to overcome.

    It is likely that primary care will go to nurse practitioners while more detailed diagnosis and diagnostic procedures will go to physician sub-specialists. The public may think that diagnoses should be made rapidly (as seen on tv) but often is does te a period of observation to determine the cause of a given person's ailment

    Most diseases are self-limited and non-lethal, but disease present in a myriad of ways in a given patient so that a knowledge of a wide variety of diseases is required. My bias would be to have my child seen bya pediatrician who has spent residency years focusing on children. If I were a high risk patient, I'd want my chest pain evaluated by a cardiologist skilled in invasive procedures including opening up a chronically occluded vessel. I want a short transit from ER to cath lab if I have an occluded vessel causing a heart attack.

    I'm expensive

    I hereby render unto rmrd the Dayly Comment of the Day Award for this here Dagblog Site, given to all of him from all of me!

    Infections have wiped out, from time to time, 25% or more of the population throughout history.

    That is a fact!

    We used to call them 'plagues'.

    Most real problems exhibit themselves in the ER.

    Rapidity is a key to individual and social medical care.

    Well done!

    The pushback against having physician income paid as salary comes from the idea that physians should be independent operators like lawyers and businessmen.

    That is not the source of the "pushback." There are very few independent doctors anymore. Like lawyers, the vast majority of private practice physicians are members of partnerships in which partners are paid according to what they bill. This arrangement has nothing to do with the idea that physicians should be independent operators. It just makes economic sense. The partnership depends its members to build the practice and incentivizes them accordingly.

    It makes less sense for large hospitals, which don't rely as much on individual physicians to attract patients. But hospitals have to compete with the private practices for doctors, which means that they must compensate their physicians comparably.

    The hospitals that salary their doctors tend to be research hospitals. They can do so because they offer academically-inclined doctors benefits that they can't get in private practice--research opportunities. Still, every doctor who goes into academia does so with the knowledge that they will receive significantly lower pay. They make the sacrifice because the work is more interesting. And even research hospitals now outsource many procedures to multi-specialty groups, as described in the NYT article, which means that an even higher share of health spending goes to non-salaried physicians.

    I see no way for the government to force hospitals and practices to salary their physicians short of nationalizing the health care system, and since that's not particularly feasible at the moment, I think we need to find other ways to change the incentive structure. The ACA pay-for-performance initiatives seem to be promising, but we'll see how it goes.

    PS Full disclosure: my wife and father are academic physicians, and my brother is private practice.

    Scumbag hospital execs:

    Health Care’s Overlooked Cost Factor
    By Eduardo Porter, New York Times, June 11/12, 2013

    When the Evanston Northwestern Healthcare Corporation merged its two hospitals with the neighboring Highland Park Hospital just north of Chicago 13 years ago, the deal was presented as an opportunity to increase efficiency and improve the quality of patient care.

    But when the Federal Trade Commission finally decided to look at the deal, it encountered an entirely different objective: to gain market power.

    Mark Neaman, Evanston’s chief executive, had told his board that the deal would “increase our leverage, limited as it might be,” the investigation found, and “help our negotiating posture” with managed care organizations.

    The commission caught Ronald Spaeth, the Highland Park C.E.O., talking about the corporation’s three hospitals and explaining how “it would be real tough for any of the Fortune 40 companies in this area whose C.E.O.’s either use this place or that place to walk from Evanston, Highland Park, Glenbrook and 1,700 of their doctors."

    It was a great deal for the hospitals. The fees they charged to insurers soared. One insurer, UniCare, said it had to accept a jump of 7 to 30 percent for its health maintenance organizations and 80 percent for its preferred provider organizations.

    Aetna said it swallowed price increases of 45 to 47 percent over a three-year period. “There probably would have been a walkaway point with the two independently,” testified Robert Mendonsa, an Aetna general manager for sales and network contracting. “But with the two together, that was a different conversation.”

    And who was left holding the bag? Not the shareholders of UniCare or Aetna. It was the people who bought their policies, who either paid higher premiums directly or whose wages grew more slowly to compensate for the rising cost of their company health plans [....]

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