Wednesday, October 7, 2009

The Wall Street Journal tries to ignite a Civil War among physicians

Yesterday, the Wall Street Journal's editorial page launched an extraordinarily deceptive attack on "Obamacare" for waging a "war" on specialists to benefit primary care.

Let's start with the WSJ's dismissive attitude about primary care. "Compared to bread-and-butter primary care doctors, specialists cost more to train and make more use of expensive procedures and technology - and therefore cost the government more money. Even so, the quiet war Democrats are waging on specialists is astonishing," says the WSJ. Yet, as ACP has documented, these same "bread and butter" primary care physicians save taxpayers a lot of "bread" by improving outcomes for diseases like cancer and diabetes and preventing avoidable hospital admissions. You would think that a newspaper that likes to think of itself as a champion of fiscal responsibility would support the importance of primary care in saving taxpayers' money, instead of dismissing them as being less valuable than other specialists.

And what's with the WSJ's implication that general internists, pediatricians, and family physicians aren't specialists in their own right? In a recent policy paper ACP describes, the highly specialized skills required to be a primary care physician: "The IOM defines primary care as 'the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.' Primary care physicians provide not only the first contact for a person with an undiagnosed health concern but also continuing care of varied medical conditions, not limited by cause, organ system, or diagnosis . . . General internists are specially trained to solve puzzling diagnostic problems and can handle severe chronic illnesses and situations where several different illnesses may strike at the same time. They are also trained in the essentials of primary care internal medicine, which incorporates an understanding of disease prevention, wellness, substance abuse, and mental health."

Now, what about the Obama administration's alleged "war" on other specialists? The WSJ mixes up, confuses, connects, and distorts several different policy initiatives: provisions in pending health reform bills, supported by President Obama, to improve the accuracy and appropriateness of physician payments; and a completely unrelated regulatory initiative (which began long before the current administration came into office) to update Medicare's relative value units. The health reform bills being considered by Congress provide a relatively modest Medicare payment increase (5% in the House bill, 10% in the Senate Finance version) for designated services by primary care physicians. In the Senate version only, one half of this increase would be funded through 0.5% offsets to other physicians. Otherwise, the proposed primary care increases are funded with additional federal dollars at no cost to other physicians. The bills also would pilot test new payment models to increase payments to primary care physicians and other medical specialists alike for working together to achieve better outcomes, and create an expert panel to identify potentially mis-valued services under the Medicare fee schedule. Yet instead of applauding these efforts to improve the accuracy and value of Medicare payments so that tax payers are getting more value for the money they spend on Medicare, the WSJ condemns them. Go figure.

Finally, the editorial directs most of its ire at a proposed rule that would increase Medicare practice payments for primary care physicians and some other specialties, but lower them for cardiologists and oncologists. The origins of this proposal go back to 2006, when over 70 specialties urged Medicare to conduct an updated survey of physician practice expenses. Medicare subsequently contracted with the AMA to conduct a new survey, and in June of this year, it asked for comments on a proposal to use the new survey to update how much it pays physicians for their overhead costs. In ACP's comments to CMS , the College urged the agency to address, in an open and transparent manner, the concerns from cardiology and oncology about the application of the survey to their specialties, as it also expressed support for updating the practice expense payments for all specialties. But the essential point that the WSJ misses is that this whole regulatory process is part of Medicare's statutory responsibility to update physician payments on an annual basis, is independent of the health reform legislation being debated by Congress, and its origins pre-date the current administration. Sure, there can be legitimate differences of opinion on whether Medicare should proceed with the proposal as announced in June, but to label it as Obama launching a war on specialists, to benefit primary care, is absurd.

The WSJ may not like the fact that there is a broad and civil consensus within medicine, primary care and other specialties alike, on the need for more primary care physicians, including reforming physician payments to support primary care. It's true that no specialty wants to take a pay cut to increase pay to another, but medicine has, for the most part, been able to engage in a respectful discussion of such issues without making this a "primary care versus [other] specialists" issue. I hope that physicians will not allow the WSJ's to turn this civil discussion into a civil war.

Today's question: What is your opinion of the WSJ editorial?


PCP said...

This is highly typical of the elite Wall street establishment.
Their disdainful view of Primary care is largely borne out of many of the mistakes of our own profession.
Take the RUC and the RBRVU system for instance. How is it possible that a system where one a general internist, a pediatrician and a family practice representative (3) out of 29 members purportedly represent 40% of physicians. It does not take much to decide who is at the table and who is on the menu. Yet the AMA felt that is an appropriate way to determine physician payments. Now that the Physician manpower numbers have become skewed out of proportion, the Gov't is entering to meddle. Why should that shock anyone? A more pertinent question is where was the foresight and maturity of the RUC over the past decade? Were they not paying attention to the NRMP results?

I will add here that medical students are not going to choose Primary care medicine with the sort of adjustments being proposed either. It will take a lot more to restore Generalism to a positive choice rather than a fall back option amongst our medical students. We will need to essentially reinvent the specialty. This is one of the reasons I have maintained that the ACP was flat out wrong in not taking on the NP lobby in the plan to push forward with the Advanced medical home. NPs and PAs should work in teams under the physician of record, even if the NP is the primary caregiver. The patient must know who their doctor is and realise that that is where the buck stops. The responsibility level required of caring for each and every american demands no less than a suitably qualified Physician.
When wall street types and specialists, and most importantly medical students see this type of policies with the relentless expansion of scope of practice of these practitioners, it does not cause the prestige associated with primary care to go up, nor subsequently do incomes, nor do any of the other factors used in making a decision. It inevitably leads to such dismissive editorials which those of us in the trenches know to be false, but which can't be reliably measured as they are in the abstract.
Medical students rightfully shun such career choices as they are quite capable of seeing the choices in front of them.
Will the specialty medical societies join us in this fight, hardly likely. Their interests have never been in seeing a robust Generalist workforce. Ironically that reduces the number of referrals, subsequent follow ups and testing done.
One other irony in all this is that medical specialists have resorted to fighting for medical imaging fees! What an irony. I would be supportive of the need for a revision of all cognitive specialty fees, but why sulk over imaging and testing fees? We all know why!
This has nothing to do with infighting, it has everything to do with righting the wrongs brought about by the RUC.

Arvind said...

Dear Bob:

I don't believe you have the authority to comment accurately on this issue. If any of the physician-members of the ACP has any issue with this WSJ article, I would like to hear it from them.

BTW, I agree with the Editorial in the WSJ. This blatant attempt by the administration to cause division amongst the physician community is a classic "divide and rule" strategy. If you for one moment get rid of your liberal bias, and steadfast support of the President, you will understand what the WSJ is getting at.
Fundamentally, the govt is saying to the PCPs "if you want higher reimbursement, you will have to rob your specialist colleagues".

And the ACP, for some unknown reason, has abandoned its sub-specialist members in agreeing with not only this outrageous plan, but also to support nonrecognition of Consultative codes as proposed by CMS.

As any civilization that has allowed itself to be divided will bear evidence, this only leads to destruction of the entire civilization. So, instead of vilifying the WSJ for being bold enough to bring truth to the print media, you would do better if you managed to challenge the CMS on these issues. I am not holding my breath for you or the ACP to do this, however.

Rich Neubauer MD said...

What do I think of the Wall Street Journal editorial? Not much.

In what sometimes seems like a lifetime ago, I was a college journalist -- first as a reporter and then as managing editor of The Cornell Daily Sun. While I understand the complexity and difficulty of getting factual information right, it is a journalistic responsibility to try hard to do so. The first thing that is wrong about the WSJ editorial is that it does not even try to get the facts right. The editorial is a wildly bizarre patched together compilation of mangled half-truths.

The second thing that is wrong with the WSJ editorial is that it goes even further toward the dark side of journalism by mixing and matching “facts” to support a preconceived notion: that “team Obama” is perpetrating a conspiracy to undermine sub-specialist care in favor of shoring up primary care. Get real.

The third thing wrong with the editorial is that the writer clearly did not research and does not understand anything about primary care. You nicely point out the disrespect the writer displays for primary care. That no attempt was made to find out more about what is going on in the legitimate discussion of the primary care system in this country is patently obvious.

Finally, in the worst tradition of journalism, the editorial seems specifically designed to be inflammatory. Granted it is an editorial, but still, there is responsibility to say something meaningful and thoughtful. The health care debate has been peppered with distortions and thinly veiled or completely unveiled attempts to distract the discussion, gain political points, and so on. But to see this in a piece of journalism from a major newspaper is disconcerting. Hopefully their attempt to stir up flames with smoke and mirrors with quickly wither.

Jay Larson MD said...

Health care reform is difficult enough without such inflammatory editorials such as the one in the WSJ. Do I want primary care to “rob” specialists … No. Do I think that procedures are over valued considering the complex cognitive skills needed to survive as a general internist, neurologist, infectious disease specialist, rheumatologist or endocrinologist…Yes. Cognitive specialists save the system money also. For instance, an endocrinologist managing diabetes well can save substantial money by reducing complications of diabetes. A good neuro exam may obviate the need for a head MRI.

Thomas Bodenheimer had an interesting article about the RVU system and primary care. In summary the article pointed out that the RVU system failed to prevent the widening primary care (or other cognitive specialties) –specialty (procedure based) income gap for 4 reasons: 1) The volume of diagnostic and imaging procedures has increased far more rapidly than the volume of office visits, which benefits specialists who perform those procedures; Because of technologic improvement and increasing efficiency over time, specialists can perform many procedures more quickly, whereas office visits cannot be shortened without reducing the quality of care or patient and physician satisfaction.
2) The process of updating Relative Value Units or RVUs every 5 years is heavily influenced by the Relative Value Scale Update Committee or RUC, which is composed mainly of procedure based specialists. Only 3 of 29 RUC members are primary care physicians. 3) Medicare’s formula for controlling physician payments penalizes primary care physicians; and 4) private insurers pay for procedures at higher levels than for office visits.

It is too bad that groups of physicians are in this divisive debate about how to slice the health care pie, but if nothing is done, the system will continue on a path of destruction.

Steve Lucas said...

From a business perspective I think it is important to remember that the WSJ is a business paper, not medical. As such, it relies on a group of high profile individuals who, more often than not, are associated with the AMA or business.

One point that has been driven home to me is the AMA is a business. A doctor recently publicly resigned and, working from memory, stated only 17% of practicing physicians belong and 80% of income is derived from business operation.

Looking at the AMA's control of the RUC and we see this groups business bias. A bias against front line physicians in favor of specialist. A group the AMA serves very well.

Moving further into the discussion, the modern practice's business model promotes nurses and NP/PA's. As doctors spend less time interacting with patients and having the nurse do the exam and followup answers the nurse has become the caregiver. People do not care about liability, they want someone to talk too.

Now add an overly aggressive computer industry that feels they can write a program to do anything and we find ourselves with front line doctors value being debased. I see the value of doctors when they have the time to properly interact with patients. This editorial only reflects the publics view of physician value, along with all of its misinformation.

Steve Lucas

Jim Webster MD, MACP said...

We would expect nothing less from the WSJ with their arch conservative bias. The way to fix the discrepancies in physician payment is to reduce the waste,(800 Billion/yr.) much of it from support specialties, inherent in the fee for service payment scheme.
On a different note, how come Liz Fowler, Bacus' senior aid, has anything to do with the reform legislation? She worked for Wellpoint from 2005-07. How about an investigation for conflict og interest? Or prosecution when she takes a job for the insurance co's next year with a huge signing bonus, a la Rep. Townsend.
Jim Webster

Unknown said...

I have lost a contracted position with a cardiology group because of threatened RVU cuts. Sadly, I view you at the ACP as dupes, having been taken for a ride by the Obama administration. When Obama took tort reform off the table, he defined himself as a political prostitute, and his "health reform plan" as a blunt instrument to strengthen the Democrat party and reward its constituents. This, from the (gasp) WSJ.

Unknown said...

To Dr. Jim Webster. If there is waste, fraud, and abuse, the Obama administration should address those issues now. It is there responsibility to spend our money wisely and enforce the law of the land. I am not sure why you choose to believe these empty promises.