Doctors, especially the primary care doctors who could help control costs, are opting out of Medicare because Medicare doesn't pay them enough. Paying those primary care doctors for their expertise and time spent following up with patients, reassuring the patients, and 'directing traffic' by referring them to the most appropriate consultants and specialists, could go a long way toward reversing this trend. Currently, since most such follow-up and managing of referrals is done over the phone, Medicare refuses to pay for it. Bringing primary care doctors back on board in an effort to control overall costs would likely save money for Medicare. One way of doing this would be to pay doctors for time they and their office staff spend on the phone with patients and with specialists and insurance companies arranging consults. Another way would be to put part of a primary care doctor's pay from Medicare on a capitated basis.
Another potential area for savings is smoothing the transition from hospital back home, especially for patients who will not be followed as outpatients by the same doctor who admitted them to the hospital.
Since the free market hasn't come up with a way to make health care available and affordable, the government needs to step in.
President Obama has put the American health care affordability crisis near the top of his agenda, and for good reason. I quite agree that the problem requires a government imposed solution. Leaving it in the hands of the 'free' market is exactly what has gotten us into this mess.
One well appreciated problem in the American health care system is the shortage of primary care doctors. This article in today's New York Times,
"Doctors Are Opting Out of Medicare,"
is a nice summary of the problem.
If Congress wants to alleviate this problem, I suggest Medicare start paying primary care doctors better. What's more, paying them better can actually SAVE money in the long run, if the better pay comes with a reasonable amount of responsibility for holding costs down.
Between Medicare and Medicaid, Federal programs already pay for a lot of the primary care in the United States. But the pay is so poor that doctors are leaving the field for greener pastures. Most primary care is done by Family Practitioners, Pediatricians, Obstetricians and Gynecologists for younger ladies, and Internists. (Internists are specialists in internal medicine; NOT trainees in their first year out of medical school -- those are interns.)
I'm an internist. Yesterday I took my tax records to my accountant so he could do my income tax return. As I was leaving, I thought to ask him if he knew any doctors looking for a place to practice. I own my office building. For years it had three doctors working there, but now I'm the only one left, and I haven't found anyone who seems interested in starting up in mostly primary care. I could use a partner or tenant to share the expense of maintaining the building. My accountant told me he knows a couple of doctors who have practices like mine, but one is ill and considering retirement, and the other recently closed his office to become a hospitalist.
A hospitalist is a doctor who specializes by taking care of patients only while they're in the hospital. That seems to save some money PER HOSPITALIZATION, probably by getting the patients out a little sooner. It may not save that much money, if any, for a given group of patients over the long term. That's because transferring the patient from the care of a hospitalist to a primary care doctor who follows outpatients probably creates more opportunity for things to 'fall through the cracks'. If something important 'falls through the cracks' during that transition, the patient may have to go back to the hospital. Any system that measures efficiency solely in terms of cost per hospitalization won't pick up on the inefficiency of preventable rehospitalization. Medicare's system of paying hospitals a flat rate for the illness treated makes hospitals focus on efficiency PER HOSPITALIZATION. Most private insurance companies follow Medicare's lead and do the same. This story from the Washington Post,
"1 in 5 Medicare patients readmitted within month"
covers a study published in today's New England Journal of Medicine on exactly this problem. Perhaps Medicare should pay the primary care doctors who'll be taking over the patient's care to make one hospital visit soon before the patient is discharged, or maybe enough to make it worthwhile to make a house call (remember those?) soon after the patient gets home. Routinely putting patients on a home health nursing service for a few weeks at least after hospital discharge would likely help, too.
Years ago, I practiced more as a younger internal medicine consultant for some older primary care doctors. I remember one old General Practitioner, "Dr. R," in particular (back then, General Practitioner or GP the term for what we now call Family Practitioners). Dr. R. seemed to spend a lot of his time just consulting one or another specialist on each of his patients. I once mentioned this to another specialist, Dr. S, whom Dr. R. would also consult. I said something like, "Dr. R. seems to be mostly directing traffic," perhaps with a touch of derision in my voice and mind. Then Dr. S taught me something I hope I'll never forget, with his reply, "Yes, and he's VERY GOOD at it. His patients seem to get excellent care." Dr. S. was right. Knowing whom to consult, and sending the patient to that specialist or calling him/her in, especially with a good introduction in the form of a brief history of what's going on with the patient, pointing the consultant toward the problem that needs to be addressed, is a very valuable talent. Dr. R's patients didn't bounce around from one specialist to another, until they stumbled on the right one, meanwhile running up a huge bill for Medicare. That often happens when patients self-refer and sometimes happens when an inexperienced primary doctor is doing the consulting. I'm confident Dr. R. didn't just save his patients time, pain, and uncertainty; he also saved Medicare a lot of money.
Talent for 'directing patient traffic' efficiently would probably be very hard to measure, but I'm optimistic most primary care doctors would like to be good at it, and would put some time, effort, and thought into getting better at it if they felt Medicare paid them enough. It would probably work even better if Medicare added a bit of recognition and some bonus money for doctors who seemed to be doing well at it, even if the measure of who was doing well was a bit arbitrary and sometimes off target.
In addition to my private practice, in the last couple of years I've gotten some experience with a health care system that is, within limits, a capitated model: hospice medicine. When a Medicare patient goes on hospice, the hospice gets paid a flat rate, currently about $120 a day in my part of the country, which is supposed to cover ALL of the patient's needs for his or her terminal diagnosis. Covering ALL of a patient's needs, even for just one diagnosis, puts the hospice in the position of being an insurance company, but there are several 'outs' that make that responsibility manageable.
If a patient needs more intensive care for control of pain or some other symptom, he can go on 'continuous care' at home with a nurse's aide there 24-7 (though the need is reevaluated every 8 hours so it's not likely to get to the "7" as in continued for a week.) The hospice gets paid more when a patient is on continuous care (a figure of about $350 a day comes to mind and may be accurate), though they usually pay the entire daily payment in overtime for extra nursing care. Another 'out' is "general inpatient care" which can be done at a skilled nursing home or at the hospice's own inpatient unit if it has one. Again, the hospice is paid more for 'GIP' days (something in the range of $550-600 a day, I think), but to accept GIP patients the nursing home usually gets paid the entire per diem Medicare allows; the nursing home does most of the work but the hospice still sends a nurse to visit once a day to keep in touch with what's happening to the patient. Also, there's a limit: a hospice can't bill more than 20% of its total patient days as inpatient days.
A third 'out' is that the patient can 'revoke' -- come off hospice care and revert to regular Medicare -- at any time. If a patient decides he wants to try some aggressive (read expensive) new treatment that the hospice doesn't cover, the patient can revoke. He's eligible to be readmitted to hospice at any time unless the treatment helps him enough that he's no longer terminal. (Medicare's current definition of 'terminal' is that the patient's condition suggests a life expectancy of 6 months or less.) A fourth 'out' (and probably the biggest one for providing insurance for a hospice patient) is, to put it bluntly, that the patient is expected to die. There's an obvious potential for abuse of that 'out', but so far I don't think that's been much of a problem. One deterrent is that the nurses and aides get pretty attached to the patients and their families. Those nurses want to be able to look at themselves in the mirror the week after a patient has died. Actually, it's often nurses who do the enforcing and the drawing of lines in the sand on medical ethics, and not just in hospice.
For a non-hospice patient, none of those 'outs' is available. An HMO can take capitated payments -- so much a year for each person covered -- as long as its patient group is big enough to balance the few expensive sick patients with a lot of healthy people. A primary care doctor in private practice, or even a moderate sized group of doctors, can't afford to take on the risk. One patient with a curable but expensively curable disease could bankrupt them. A market solution to the problem is imaginable, but it doesn't exist: If insurance companies offered some sort of reinsurance policy that primary care doctors could buy, that would cover the cost of treating those 'expensively curable' diseases, the primary care doctors could accept capitated patients. BUT the reinsurance would need to kick in before the costs for a given patient got ruinous, and would need to be cheap enough that it wouldn't sop up most or all of the capitated payment. If any such reinsurance is available, I haven't heard of it. Insurance companies have gone into the business of insuring against some hard to measure risks, but so far is has been mostly the risks of subprime mortgages defaulting. Seeing how that worked out, I doubt any insurance company is soon going to look for ways to branch out into the business of insuring against the risk of a cluster of patients with expensively treatable diseases.
So, since the free market hasn't come up with a solution, and the unsolved problem is a major drag on the economy, the government needs to step in. We need a government health insurance program that pays doctors to hold down costs, but without severe penalties to the doctors for those expensively curable patients on whom cost control just doesn't work. The system also needs to avoid or at least blunt any perverse incentives -- for example, any incentive to let an expensive but curable patient just go ahead and die to save money. Any such system would likely involve paying primary care doctors more, not less. My pet idea is for Medicare to pay primary physicians partly on a capitated basis: Encourage every Medicare beneficiary to sign up with a primary care doctor, and pay the doctor a few dollars a month for each patient, as long as the patient stays out of the hospital. If what Medicare pays for a primary care doctor's usual services, like office visits, weren't so low I'd suggest reducing the scale somewhat to finance the capitated patients. As it is, with doctors bailing out of primary care for Medicare patients, I think the capitated payments should simply be added to the current pay scale, as an extra incentive.
How bad is it for primary care doctors treating Medicare patients now? Pretty bad, as that New York Times article made clear. One former 'profit center' (which could also be called a dirty little secret) that helped primary care doctors get rich/stay in business was the markup on lab tests. Some private insurance plans still let a doctor bill directly for blood tests done on blood samples the doctor draws but sends out to a 'reference lab'. Medicare stopped doing that years ago. On lab we send out from my office, all Medicare pays is a fee for drawing and handling the sample. They pay $3.00. Last week I had a patient on whom I ordered quite a number of tests, including some that I don't commonly order. The lab technician needed fifteen minutes just to fill out the paperwork, and that was after he'd drawn the blood samples. Then, over the next three days, the patient telephoned me twice to ask about the results. I discussed them with her over the phone. Most of the tests were normal -- the only thing we found was a mild anemia likely due to a marked iron deficiency -- but the phone calls took me a good 15 minutes. If there had been something else abnormal, I probably would have referred the patient to a specialist, which would have taken more telephone time -- especially if I did it RIGHT, speaking to the consulting doctor myself, which makes his job simpler, more effective, and perhaps cheaper.
Last week I had the impression that Medicare had started paying for telephone time. My office manager noticed that there are billing codes for short, medium, and long telephone calls, so I carefully kept track of my calls for a week. It added up to a good bit of time. Then, this week, my office manager checked with Medicare on whether they would pay for those calls. Guess what -- they won't. The billing codes exist, but Medicare doesn't pay anything if you submit bills for those calls. My office manager asked sarcastically if I was just supposed to hang up on those phone calls, or tell the patients they had to come back to my office to discuss things. The lady from Medicare said yes.
I can't resist making a comparison to another profession: Try making a phone call to a lawyer with a follow-up question about something you've recently consulted him on. For anything more substantial than, "No, we're still waiting to hear back on that," you can expect the meter to start running. How fast? A minimum of $200 an hour, for any lawyer who's been in practice a few years. (I seem to recall that Kenneth Starr proudly quoted his usual fee at $395 an hour, and that was several years ago.) If your lawyer is good enough to keep track of time by tenths of an hour, a quick phone call could be as low as $20. Some lawyers go by fourths of an hour, so the minimum, at $200 an hour, would be $50. And I can't resist pointing out that back in college, a lot of the pre-law students are former pre-meds who couldn't pass organic chemistry.
Perhaps it's a conceit, but I happen to think my phone calls about patient care are as valuable as the ones my lawyer bills me for. One way or another, Medicare should pay me for them.