Wednesday, July 8, 2009

The summer of internists' discontent

A review of the comments posted to the ACP Advocate blog would suggest that internists (or at least those who take the time to read and respond to my posts) are a pretty disgruntled bunch.

Primary care internists express unhappiness that health care reform is not going to raise their fees by enough to achieve parity with other specialties. Many also resent the encroachment of nurse-practitioners. As one of commenter wrote, "Far from having a rejuvenated PCP workforce, we will end up with an angry, bitter, fed up and revolting specialty workforce, with manifestations such as disinclination to take call, cherry picking referrals, early retirements and other such actions that will make a PCPs life far more difficult." Even when the news is positive, such as my blog about a Medicare proposed rule to yield a 6 percent increase in total allowed Medicare charges to general internists, the reaction was, well, less than enthusiastic - "tossing primary care a bone" is how one comment described it.

Subspecialists aren't a happy lot, either. Cardiologists are livid that their total Medicare allowed charges would be cut by 10% under the same CMS proposed rule. Endocrinologists are upset about a proposal to eliminate higher Medicare fees for consultations and to redistribute the savings to other evaluation and management codes.

Single payer advocates are mad that the College hasn't endorsed a Canadian-style health care system. Conservatives take issue with just about anything that smacks more government involvement in health care. Some of our members want ACP to enthusiastically embrace a public plan option, while others want us to vigorously oppose it.

Even ideas championed by ACP itself, like paying internists for the work involved in care coordination through a qualified Patient-Centered Medical Home, are viewed with skepticism by some ACP members, especially those in smaller practices, and outright hostility by some.

I bring this up not because I have a problem with internists' expressing their views, even when sharply critical of proposed health care reforms and the ACP itself. The blogosphere is not a place for thin-skinned people.

But as we debate what is wrong with the health care reform prescriptions coming from Washington, I hope we don't lose sight of the consequences if health care reform fails.

Does anyone really believe that doctors and patients will be better off if health reform falters and we continue the status quo? If the ranks of the uninsured are allowed to grow? If insurance companies are allowed to continue to turn down or charge exorbitant rates to people with pre-existing conditions? If small businesses can't hire people and pay decent wages or even keep their doors open because of the rising costs of health plan premiums? If the Medicare trust fund is allowed to go broke? If health care reform dies, and along with it, our best chance to begin to restructure workforce and payment policies to support primary care?

I believe that the U.S. health care system is a train wreck in waiting, and that 2009 may be our best and perhaps only chance to put it on a safer track. We have within our grasp the chance to enact legislation to provide affordable coverage to most Americans, to make the cost affordable and sustainable for families and businesses, and to begin to rebuild the primary care physician workforce. Yes, I understand why so many internists are unhappy with the way things are, and distrustful of the changes being proposed to make things better. I also respectfully suggest that there will be far more reasons for internists to be discontented if health care reform is allowed to fail.

Today's question: Do you think internists and patients will be better off if the effort to reform health care collapses?


Robert J. Sobel, M.D. said...

The crystal ball I do not have. The current phenomena that breed the resentment we feel should clearly change. This will involve aggressive deconstruction. In the absence of the elimination of interference with clinical autonomy (pharmacy benefit operations, prior approval, unjustified financial coercion), I would argue that whatever new laws are enacted should not be referred to as reform.

It is too easy to claim that the bubble of health care reflects physicians run amuck. To the extent it exists, it may still be less expensive than the under-treatment of so many diseases whose burdens we can mitigate (hypertension, diabetes, hypercholesterolemia, vitamin D deficiency) and the costs of their sequelae.

We are at risk of being trapped in a new bureaucracy that will cause the last vestiges of independent practice to vanish. A solution that leaves the current Hatch-Waxman law intact will necessitate more bureaucratic battling to referee the cost effectiveness arguments and, thus, nullify the savings. It will continue to subjugate the patient-physician relationship to the "needs" of the third parties. The cost controls of the Medicare fee schedule have to be applied to drugs and new technologies (Regulated Royalties). We can afford as much Lipitor, Coreg, GI-friendly metformin formulations, clean SSRI's, and introductory priced new agents as needed. Pay well the protected, deliberative, patient-physician encounter and its necessary ancillaries. Finance this via the immediate savings of eliminating pharmacy benefit harassment, disease management duplication, unreasonable marketing expenses, and the publically-traded for-profit status of insurance companies or health care corporations. Do not buy the argument that we have to pay exorbitant prices up front that totally unbalance the health care pie.

A good primary care physician strives to keep his patients away from the hospital as often as possible. There is still time to treat us well. Deconstructing the vestiges of the managed care fallacy is the only path to true reform. If we continue to be lured by the language of standardization, information technology efficiencies, pay for performance, and integrated systems, we will further erode the accountability and humanity that seems to have vacated so much of modern American enterprise.

Jay Larson MD said...

All complex systems ultimately reach equilibrium or the system collapses. The health care is no exception. If health care reform collases, then the health care system will collapse. Even if health care reform occurs, it still may not be enough to stop the health care system from collapsing. Either way there is a light at the end of the tunnel. Our health care system is very broken and can not sustain itself. If meaningful health care reform occurs or if the health care system ultimately collapses, patients and internists will be able to resume a healthier relationship with the goal of improving health and not playing the money game.

BTW, I don't consider the reform as "taking away" from specialists to "give" to primary care. It is just a matter of decreasing the value of over-valued procedures and increasing value of cognitive skills. Procedurists can always use their brains if they want to.

Joseph said...

No question, if the health care system remains as the status quo, it will collapse., From its rubble will undoubtedly emerge painful and stringent global budgets and the Big "R" word will stand at the entrance of every venue in the delivery system. Even though everyone's wish list will be pruned, I believe we need to continue together the fight for reform that moves the quality and coverage of health care in the right direction before it is too late.

DrJHO7 said...

I think USA health system reform is essential, and without it, the collapse of the system we have is foreseeable. Without question, the status quo is unsustainable.

I share the concern that the "us vs them" mentality that could be created by redistributing income from "specialists" to primary physicians will divide the house of internal medicine and probably undermine the commitment of ACP's membership to speak as one voice at the health care reform table.

In the absence of reform, employer health insurance premium costs will continue to rise, and more individuals will join the ranks of the uninsured as employers throw in the towel and shift more and more financial risk for the health insurance premium to the employee. Patients would receive less timely care, diagnoses would be delayed, then costs of care would be higher for later stage disease processes, physician and hospital revenues would drop...the cascade is scary to consider.

As internists, we have little choice but to live with whatever reform comes down the road from the government. We exert nearly constant pressure on the legislators as individuals and through organized medicine, and our input is variously considered, but we have very few choices: our options are whether or not to continue to practice medicine, whether to retrain in a new specialty, whether to continue to accept medicare assignment or participate in mcr at all, etc.

With ACP recommending an immediate 10% boost in reimbursement to the primary care sector, followed by 7-8% annual increases for 5 years, successively, to start to close the 2-3 fold income gap between primary physicians and "specialists", the response of 4-6% one time boost from the government to primary care physicians is anemic, a token (and a disappointment), but it is "better than nothing" (also better than PQRI). It is a small step in the right direction. We have little choice but to take it.

The intangible rewards of general internal medicine practice have always been there, and probably always will be. It's fun and interesting work, relationships with patients are challenging but satisfying - it's good work.

But will any of these positives draw the new generation of physicians back to the primary care specialties with their high debt, the 2-3 fold income gap (3.5 million dollars difference over a career)and the perceived high hassle factor and low self esteem of these specialties?
Not yet: the driving force for the return of the sine wave toward this median has not come into focus yet.

Kate Burton said...

I am a three year cancer survivor and I want to thank every doctor that I have ever met. That being said the bulk of the cost of my treatment was not my physicians fees but instead medications that were required for chemotherapy.

I am insured so did not feel the bulk of the costs but am well aware of what they were. for example I had 12 rounds of chemotherapy. The cost of the chemotherapy agents was not particularly high but after each round of treatment I had an injection for my red cells and one for my white cells. Combined they cost $9,000 dollars, $108 thousand dollars over the course of treatment.

Perhaps if the ACP were able to work with the administration on the cost of pharmaceuticals some real progress could be made.

Do not get me wrong, I don't have a problem with allowing the companies be re-paid for R&D costs but these were not brand new medications and had been paid for long ago.

I continue to be employed and as such I am insured. If something were to happen either to my health or my job that not longer allowed me to work I would join the ranks of the uninsured and the uninsurable. A public option must be put in place for people who are in that position.

jfddoc said...

I'm waiting to see how the anticipated Jan 21% Medicare cut is going to be addressed.