The New England Journal of Medicine** publishes a doctor’s lament on practice restrictions:
Many strategies for the containment of medical costs have emerged from systems of managed care — gatekeeping by a primary care physician, prior authorization and utilization review, assumption of financial risk through capitation payments to the provider with financial disincentives for hospitalization or referral to specialists, and so forth. But another feature has crept into the managed care formula and has been largely overlooked: that of slowing and controlling the use of services and payment for services by impeding, inconveniencing, and confusing providers and consumers alike…
This is a common complaint. A bureaucrat gets in between a doctor, their decision making and the patient’s best interest. This comes in many forms. The big ones are payment reform efforts that shift risk to provider led entities for the entire episode or global budgets for a given population instead of individualized widget payments. All of those introduce financial criteria into what should only be clinical decisions.
The ACO models are proliferating. Bundled payments are becoming more common. HMO gatekeeper models are quite popular on the Exchanges. There is an imposition of another layer of complexity on clinical decision making.
In some ways, there is very little new in health policy. Most things to contain costs have been tried at some point, they worked to some degree and then push back happens as the way to control costs is to have the payers maintain a credible threat to say either “No” or “No, not at that price”.
OOOPPPPPSSSS…
This complaint is from 1989.
ACOs are mostly a repackaging of the provider led HMO model with better data analytics and risk adjustment.
Global payments are supersized capitated payments.
HMO’s are HMO’s.
EPO’s are HMO’s with fewer gatekeepers.
There is very little new, just different ways of applying the same few incentive structures to different chunks of the system.
** N Engl J Med 1989; 321:607-611
DOI: 10.1056/NEJM198908313210909
Steeplejack
What are ACOs and EPOs? That is, what do the acronyms stand for?
Frank McCormick
ACO = Accountable Care Organization
EPO = Exclusive Provider Organization
Barbara
It’s very hard to get doctors to see that a lot of the problems associated with health care expenditures revolve around them, their decisions both medical and lifestyle. It’s not like they control the process that created the ecosystem in which they practice, so in that regard it’s not their fault, but that is why most of the “solutions” revolve around hemming in their freedom. It’s also why I found it amusing to see the reflexive criticism of NYU’s decision to stop charging tuition for medical school as a waste of resources. In my view, it’s exactly the kind of radical departure from the way things are that is needed to jump start a change from how doctors are trained and socialized to keep feeding the beast. Whereas, the opposition is heavy with the same cost-shifting mindset that bedevils too much of American medicine — e.g., charge tuition and then find the truly worthy candidates and subsidize them, creating an infrastructure that requires identifying and tracking the subsidies and how they are used. No, just make it LESS EXPENSIVE for everyone.
p.a.
Are American doctors overpaid? Are American specialists overpaid?
If yes, are there market functions to correct this instead of gvt. functions? (Ignoring for the moment political realities. *koff*AMA*koff*)
Barbara
@p.a.: Doctors are not underpaid, but PCPs are underpaid relative to specialists, with the result that we have seen a huge generational shift in the proportion of doctors who are PCPs versus specialists. This shift has been hidden because of the large, existing base of primary care doctors that was already in place but who are now retiring. It is attributable to the ridiculous way that Medicare has come to set reimbursement for physicians, which values doing procedures and testing over judging whether those procedures or tests are actually necessary, as well as the way medical education is subsidized and all the echo effects of those policies.
DHD
@Barbara: Interesting, this means that US Americans are about to get a big mouthful of the problem of access to primary care that has plagued other countries for decades now, and which the American healthcare lobby has repeatedly used to scare people about “socialized medicine”. This reminds me that I had an interesting conversation in a Canadian airport with a retired American doctor the other day who said that he and his wife had to decide where to retire essentially based on the availability of doctors who would accept Medicare patients. (a lot of places didn’t have any)
Of course, in the American system, the privileged few will always be able to buy their way out of the waiting lists and bureaucratic snafus, and policymakers and public opinion-makers nearly all fall into this category, so everyone will continue to conclude that there is no problem.
StringOnAStick
@Barbara: I suspect there is something about getting out of medical or dental school with 6 figure debt (like $500,000 for orthodontists) that makes the new professional just a bit more likely to side with the “doctors are saints and deserve every penny” attitude so many display; just spitballing here /.
Seriously though, I look at the lifestyle of a Canadian radiation oncologist I’m friends with, and what the average US doc has as far as vacation, hours, the fact that the former gets a 3 month sabbatical every 5 years, and I see a huge disconnect. Sure, Canadian docs make less money. They also didn’t get out of school with huge debt, didn’t have to go further into debt to buy into a practice, and they don’t have to move heaven and earth to get someone to cover for them if they want to take a vacation because that’s handled by the system. I am uplifted a bit by seeing that there is a subset of new US docs who really wanted to become MD’s to help people first, and that they’re getting noisy about it. Anyone who works in health care here has seen things go insane over the last 20 years.