Problems With Fee For Service Medicine
Wonks Anonymous is not against single payer health finance. It is a simple and practical way to replace our terminally dysfunctional health insurance industry - for more on this topic see the health insurance index of this blog. Nevertheless it has its problems. To Wonks Anonymous the main problem is that it preserves our antiquated fee for service billing system and this in turn encourages us to think and practice in ways that are not really compatible with good medicine.
An example of the sort of distortion that arises under a single payer system with controlled prices appears in the blogs in today's NY Times. Here we read the story of a talented doctor who has specialized in care for elders but has been forced to quit.
The reason? Medicare pays for procedures and services and not for the lengthy, listening, consultation and explanation that good care for elders with complex problems demands. This doctor, like many teachers before her, is being forced to choose between pursuing a career that she loves and providing her children with a decent standard of living.
The story has a moderately happy ending. She is still involved in elder care but now works as a consultant to help design treatment programs for families - who Wonks Anonymous presumes are not getting adequate attention from physicians who themselves are trying to make a living faced with a system that only pays them for doing things and not for talking and listening.
We might solve this by trying to raise Medicare reimbursement rates and this would no doubt be a good thing. We might also want to consider paying doctors to develop and maintain relationships with their patients. Which model would involve to payment of a monthly or annual fee to the doctor or medical group to provide coordinated medical care. The fee would naturally be based on the patient's condition and risks and difficulties of treatment.
Which proposal can be found in more detail in the post Squaring The Circle in this blog.
Dr Garth Kirkwood, who is a excellent thinker and advocate on this subject, would doubtless disagree. Nevertheless I offer this observation to him in particular.
An example of the sort of distortion that arises under a single payer system with controlled prices appears in the blogs in today's NY Times. Here we read the story of a talented doctor who has specialized in care for elders but has been forced to quit.
The reason? Medicare pays for procedures and services and not for the lengthy, listening, consultation and explanation that good care for elders with complex problems demands. This doctor, like many teachers before her, is being forced to choose between pursuing a career that she loves and providing her children with a decent standard of living.
The story has a moderately happy ending. She is still involved in elder care but now works as a consultant to help design treatment programs for families - who Wonks Anonymous presumes are not getting adequate attention from physicians who themselves are trying to make a living faced with a system that only pays them for doing things and not for talking and listening.
We might solve this by trying to raise Medicare reimbursement rates and this would no doubt be a good thing. We might also want to consider paying doctors to develop and maintain relationships with their patients. Which model would involve to payment of a monthly or annual fee to the doctor or medical group to provide coordinated medical care. The fee would naturally be based on the patient's condition and risks and difficulties of treatment.
Which proposal can be found in more detail in the post Squaring The Circle in this blog.
Dr Garth Kirkwood, who is a excellent thinker and advocate on this subject, would doubtless disagree. Nevertheless I offer this observation to him in particular.
Fee for service from a single payer is a good (maybe the best) way to pay doctors provided that conflicts of interest are removed, or, at least, the potential for same is greatly diminished.
1)Remove billable non-invasive testing from doctors' offices and relocate it to outpatient testing facilities, which have independent contracts with the single payer, and which are not allowed to have any financial-business relationship with referring doctors. Doctors can no longer submit bills for these tests, nor are they allowed to have financial investment in outpatient testing facilities. With this conflict of interest, THE MORE YOU DO, THE MORE YOU MAKE, removed, a doctor can order a test as often as he/she feels it is necessary without the attached stigma: He/she is ordering the test just to make money.
Now, we are left with paying for the visit itself, since other billing, in general, will not be generated by the doctor for outpatient visits to his/her office. I suggest generous, standardized (across all specialties and across the country) payment for office visits because of the time consuming, difficult work that they entail, which includes study of and ongoing comparison of the ordered tests, performed at the outpatient testing facility. The inconvenience for the doctor of the latter, as opposed to having the test done within the doctor's office, is a small price to pay for having this conflict of interest removed from their practice.
Will doctors start seeing patients back in the office too frequently? NO, I don't think so, because first, I don't believe that patients are seen back frequently enough now, and second, the increased volume resulting from a single payer system will greatly diminish the potential of this conflict of interest. These thoughts apply mostly to adult medical (non-surgical) doctors and their outpatient work. Inpatient work and invasive procedures performed by the doctor himself/herself require separate discussion and mechanisms of payment.
I discuss these and other concepts in chapter 7, "Payment of Doctors for Their Services," in my book, EQUAL HEALTH CARE FOR ALL, now available as a free download from my web site.
Regarding salaries for doctors, I can discuss and contrast my views with those of Wonksanonymous in a separate post, if he will start the discussion. Thanks for the space to write my thoughts.
R. Garth Kirkwood MD
http://www.equalhealthcareforall.org
doctor_k@equalhealthcareforall.org
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