Are we “paying doctors to ignore patients?”
Dr. Peter Bach, who practices at Memorial Sloan-Kettering Cancer Center in New York and who advised Medicare and Medicaid (CMS) from 2005 to 2006, penned an editorial with this same title – “Paying Doctors to Ignore Patients” – in today’s New York Times. As bad as is sounds, Bach is right.
Physicians who are paid on a fee-for-service (FFS) basis are paid per service they provide, whether this service is a surgical procedure , a PET/CT scan, or an office visit. The more expensive services are reimbursed more handsomely. (This scheme does not apply to physicians who are reimbursed by capitation or on other prospective payment systems.)
FFS reimbursement and other retrospective forms of payment reward the provision of services and the provision of expensive services, such as imaging, and provide a disincentive for provision of core services such as a physical examination and interview (what those of us in the health care industry call an “H&P,” or “history and physical”). Services such as H&Ps are not profitable — Bach points out how the doctor’s best money-making proposition is to provide short visits and use as much technology as possible, as patient turnover and use of expensive technological services results in an improved bottom line.
Earlier this morning, NBC’s Today show described how we may be exposed to unnecessary radiation through a proliferation of x-rays, CT scans, and other diagnostic tests that may not be completely necessary when performed. It would be difficult to prove that this trend has no underlying economic reason.
How can we pay doctors to spend more time with patients and spend less time sending patients for diagnostic tests that may be misguided?
The fee-for-service (FFS) reimbursement system that is used in the United States must certainly contribute to the overuse of expensive services. The U.S. boasts advanced medical technology, but having this technology available does not mean that its use is always necessary or appropriate. Americans, I think, equate the use of expensive tests with quality care. Yet a plethora of blood tests and scans are often used as a substitute for actual time spent with patients to discuss the problem and obtain a full history and physical. The payment structure for health care services supports this kind of practice (and some may argue that it is the very cause of this kind of health care). While physicians certainly wish to help their patients, they cannot ignore the financial aspects of their work, and FFS payments offer considerable incentives for ordering many expensive tests while discouraging spending time speaking with patients. In other words, CT scans and MRIs offer a lot more “buck for the bang” than doing an H&P (no, I’m not confused, I mean more money for less work/time). The FFS system also makes it difficult for physicians and hospitals to improve the quality of their care because reducing cases of illness and rehospitalizations actually reduces their revenue. For example, if a hospital institutes the use of new, more effective antibiotics to treat pneumonia in patients, they will improve the quality of care by reducing mortality rates, number of days in the hospital, and overall costs for the care of those patients. However, they will also receive less reimbursement, which means that their improvement in quality of care is actually costing (or losing) the hospital money. Meanwhile, a mistake in treatment that leads to a more serious illness or complication requiring treatment and/or rehospitalization will result in more payments to the hospital. The current FFS reimbursement system seems to encourage wasteful, poor quality care by rewarding extensive testing and performance of procedures and discouraging patient-provider interaction and initiatives to improve quality. This payment structure, along with many other components of the U.S. health care system, is in need of reform.