Saturday, December 20, 2008

What are we doing?

Take a minute and read through this article from the NY Times. It's a great review of the nefarious doings at Merrill Lynch right before their house of cards caved in. In 2006 the division of Merrill concerned with bundled mortgage securities distributed close to $2 billion in bonus payouts to about 2,000 employees. The head of the unit, Dow Kim, received $35 million for his efforts. Of course, the "profits" claimed by Merrill during the housing/real estate boom were based on smoke and mirrors. The mortgage derivatives market collapsed (unsurprising, in retrospect) and the consequences shook the foundations of Wall St. Lehman Brothers went bankrupt. Merrill was acquired by Bank of America, ending 94 years of existence as an independent firm. And our government sanctioned a $700 billion bail out of the corporate barons of high finance. $700 billion buckaroos. $700 billion. Another $80 billion was fronted to AIG. And just this week, W approved a plan to grant the auto industry $13 billion now, with more to come in the spring.

To put that in perspective, we've spent somewhere around $600 billion thus far to finance the war and occupation of Iraq since the 2003 invasion. And that's over five years. Our government just forked out 30% more than that in a matter of weeks. We throw these numbers around like it's nothing. The word "billion" apparently has lost all connection to reality because, hey, the federal government can just dole out checks with nine zeroes after the integers whenever they feel like it. But it's a lot of money. The entire budget for the Departments of Education and Labor combined for fiscal year 2009 is "only" about $120 billion.

So what does this have to do with medicine? Not a whole lot. I admit that I'm probably stretching it a bit here. But we do have a crisis of epic proportions in health care. Too many people either don't have enough coverage or aren't covered at all. Morever the cost of health care is rising at astronomical levels. In 2007, we spent $2.3 trillion dollars on health care expenditures. That's 16% of our entire GDP. Finally, we face an impending shortage of the very professionals needed to provide the sort of cost-efficient, excellent care that any all-inclusive health care reform would hope to implement. Younger doctors are opting to pursue careers in higher paying, less stressful specialties rather than slogging through the rigors of a standard primary care practice setting. And who can blame them? Graduating from an accredited medical school in the country oftens saddles you close to $200,000 in student loans. Now we have a President who has made it very clear that he has every intention of rectifying most if not all of our deficiencies. And he's going to need doctors who buy into it and want to make it work. So that puts us in the driver's position, right?

Well then I read the vitriolic op-ed piece in Emergency Medicine News by the eminent Dr. Jonathan Glauser (from the Cleveland Clinic Foundation of Higher Medical Instruction and Sophistication) where he basically embarasses himself in front of the country in writing. The article is hilarious.

Countering the idea of improving payments to primary care physicians he writes:

Say what? Fund physicians to promote primary care? Why throw good money after bad? If ever there was a group that has failed in providing care, it is our primary care system. To fund such a venture for groups that are singularly inept at performing anything of value to society is pure folly and a waste of precious health care dollars.

Now that's just schoolyard bully talk. It's harmful only in the sense that it damages the professional reputation of a singular ER physician on the banks of Lake Erie (I'm sure Toby Cosgrove's henchmen have "taken care" of this little problem). It's a rant by a nut-job. Why should any of us be bothered by it? This is like being worried about the state of the NFL just because OJ Simpson is in the Hall of Fame. Dr Glauser wrote an extremely shallow, poorly thought-out, amateurish, overly emotional piece that surely, given his education and prominent position, he now regrets. And that ought to be the end of it.

But my concern is with a commonly held position that this sort of attack on primary care is just the beginning. The Medical Webmaster himself, Kevin MD, hints at this in a post from last week:
The nature of budget-neutral reform means that physicians like Dr. Glauser will take a substantial pay cut to adequately fund primary care.

He's merely laying out the groundwork for a furious specialist assault on primary care that will be sure to come.

In other words, all specialists deep down harbor a fear of any sort of remuneration reform and it's going to lead to irreparable animosity between the overpaid specialists and the true soldiers of American health care, the noble internists and family practice docs.

Unless I'm misinterpreting things, this is an entirely disingenuous stance. As Max Baucus avers, any payment reform will need to be conducted in a "budget neutral" manner. That means the current pool of health care dollars that is directed toward physicans will not be increased, it will just get divvied up differently.

And why are we comfortable with this? Why, as professional group are we content to passively take whatever federal regulators want to give us? Why is it a done deal? This "spat" between the Kevin MD faction and the Jonathan Glausers of the world is just what the government and insurance companies and everyone else wants. Infighting and disunity. Physicians battling each other over ever diminishing scraps. It's the wrong outlook.

I have my own issues with the theory that simply increasing your family practice doc's pay is the fundamental solution to our nation's health care ills. If a doc has to see 30 patients a day to make 130,000 grand a year and you increase his pay so that he is compensated, let's say $150,000 a year, you really haven't solved any problems other than the one specific problem of low primary care pay. That family doc still has to see 30 patients a day. He still will need to keep his office booked for months in advance. He still won't have much time to take care of emergent issues, shunting acute problems off on the ER. The internist will still need to see the same number of inpatients to reap the rewards of higher pay, thus perpetuating the shotgun consult method of practicing medicine. Nothing really is going to change with a modest alteration in the salary structure. We need to aim higher. After all, there's plenty of money out there, apparently. Just ask the failed barons of Wall Street.

Rather than dutifully accepting "budget neutral" reform, consider the following:

1. Make it financially doable for doctors to spend time with patients. Instead of thirty a day, what if you could see five in the morning and five in the afternoon? And you had scheduled gaps to account for acute care issues that arose unpredictably? Think of how thorough you could be. Think how many fewer consultations would be necessary.

2. Student loan forgiveness for those who pursue primary care/internal medicine.

3. We'll need more doctors

4. Market forces alone will make it unsustainable for graduating medical students to opt for speciality careers, assuming that better paid doctors who can spend more time on individual patients will not need to rely on specialist consultations as before.

5. It's going to cost a lot of money

Listen, change is coming. It's inevitable. Obama has his mandate. But he's going to need us, and I stress us, all physicians, to make it work. Without the cooperation and enthusiasm of all doctors, the Obama revolution is doomed to a similar outcome as that seen in the 1990's with HillaryCare.


The Happy Hospitalist said...

Nice job doc.

Anonymous said...

I think you are right. I'm a well trained family doc who graduated with honors from medical school. I remember beating the dermatologists and radiologists on most of the exams we had. I chose primary care out of interest, not because I'm a stupid jerk who couldn't do any better. I trained at two well known university hospitals and passed my boards in the 98th or 99th percentile. I am CAPABLE of taking care of way more medical problems my patients have than I actually do. Why? I don't have time. When the patient has three complex new problems, I have to refer out at least one of them. If I spend 45 minutes doing it right, I will have generated only slightly more than 1/3 the revenue of three 15 minute visits. That's the tyranny of primary care--patients present with multiple issues, and we get paid one low fee no matter how much work we do. I often do the work of a dermatologist, orthopedist, and gastroenterologist in one visit which pays $88, but would have cost Medicare $1000 or $2000 if the patient saw the three specialists who would then order multiple tests. Yet, because primary care is not valued to the point it's disappearing, this really inexpensive and pretty high quality care I can provide won't be around much longer. It's so absurd. I would LOVE to be paid enough so I could do a complete, thorough job with each issue, the way I was trained in medical school and residency. I would refer far less, and overall costs would go down. But as you say, that would put a lot of specialists out of business, so I doubt it will ever come close to reality.

Anonymous said...

I think Dr. Glausers just upset because his Official Cleveland Clinic Photo looks like a Sex Offenders Mug Shot, check my blog if you doubt me...And good on ya Annonymous, makin me feel guilty for the reasons I chose Anesthesia, gettin to wear Wcrubs 24-7 and goin home at 8am the day after bein on call....

Anonymous said...

The primary care docs in a rural area near me don't even make 100K with seeing as many patients as possible on a given day. The Medi-care penetrance is so high that the docs can't make money. One of the NPs who used to be in private practice with one of these docs left to come to the city since he could make more (and nearly 150% what his former doc colleague is making an hour away).