Fee for service is not the root of all evil

By | May 15, 2019

Some people think that the solution to better-supported primary care is in direct primary care/salaried physician payment models. I don’t think it is the best answer. I realize money is not the only motivator explaining why people perform work. Meaningful work matters too. But meaningful work that is not respected and paid for will not sustain or be the source of burnout and resignation, not only for physicians.  I think more work should lead to more pay. It’s what causes people to hustle and go the extra mile.

Fee for service is not the root of all evil; how physician services are valued is the problem (built on top of the often unrealistic expectations of many Americans of what a healthcare system should be expected to provide, but that’s a point for another day). If you want the cardiologist to do fewer echos and caths, pay him/her a little more to talk and a lot less to cath. (It’s actually a little more complex than this, but this would go a long way to reduce silly utilization.)

I refer you to two papers: one for your heart and one for your head. The heart paper is a great piece by Danielle Ofri, MD who talks about what it’s like to care for a complex patient. She bravely confesses she did what all primary care physicians are forced to do: generate unnecessary referrals because we are not paid to slow down and think.  The brain paper is an analysis we did of the limiting effect of the American Medical Association’s CPT system on family physician billing. Bottom line is that in 60 percent of the visits, the physicians did more cognitive work than there exists a CPT code to tell the computer what work was done.

To summarize, the suppression of primary care starts at the AMA, which has created a coding system to report physician work that only focuses on one body part at a time, disrespects prudence and uncertainty, and completely rips off a physician who can take care of 6 separate issues in one visit.  CMS then adopted this coding system and added on top of it a payment system that incentivizes over-testing and over-treating, further disrespects comfort with uncertainty, and disincentivizes doctors from talking patients out of antibiotics, MRIs, and so on. Add to this layer upon layer of work they expect us to do for which there is no code to tell a computer what we did: paperwork, calling pharmacies, talking to family members, and so on.  Then layer onto this the insurance industry that just reapplies all this governmental disrespect to the private sector.

Richard Young is a family physician who blogs at American Health Scare.

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