Money makes the world go around

A colleague gave me a copy of this editorial in the New England Journal of Medicine yesterday, and I think it makes some good points.

Rapidly rising health care costs over recent decades have prompted the application of business practices to medicine, with the goals of improving efficiency, restraining expenses, and increasing quality. In the wake of the current economic crisis and the advent of a new presidential administration, even more attention will be focused on containing costs in the health care system. Price tags are being applied to every aspect of a doctor's day, creating an acute awareness of costs and reimbursement. Physicians are now routinely provided with profit-and-loss reports reflecting their activity, and metrics are calculated to measure the cost-effectiveness of their work. Many business managers believe that clinicians will change their behavior to meet the imperatives of increased efficiency, cost containment, and improved quality only by increasing their focus on the flow of money in their work environment.
I have written about this before, and can verify that the above is true, at least in my experience. I regularly get reports from my employer giving me feedback about my "productivity," which is expressed in terms of relative value units, or RVUs. The higher the complexity of the history, physical and management, and the more RVUs are assigned to a particular patient encounter.

But are there unintended consequences of applying a business mindset to medicine?
Um....yes. I think it is safe to say that many (if not most) medical providers are acutely aware of how much time they have to see their patients, how many they must see to generate the expected revenue, and how scrupulously they most document in order to get the third-party payers to cough up the dough. This obviously has an unintended effect by pressurizing interactions with patients, and inducing a sort of brusqueness of approach. No matter how hard I try to silence the little stopwatch ticking in the back of my head, I am always aware that time is money. That being said, I think the authors overstate their case a bit.

Not long ago, we overheard two colleagues talking in the hall. One physician asked the other for his thoughts on a complex case; despite a busy schedule, he did not hesitate to stop and engage in thoughtful discussion. Now, imagine that they had just left a departmental meeting where the divisional budget was reviewed and goals for individual relative value units (RVUs, the monetary metric of physicians' time and effort) were presented. Would their interaction be different?
Perhaps I am hopelessly naive, but I don't see the interaction above being affected to the degree that the authors imply. I am always happy to discuss cases with other providers, whether in my office or calling for consultation. Similarly, I have almost always been treated with the utmost attentiveness and courtesy when I phone colleagues at other institutions for advice or information.

Researchers have described two types of relationships that involve giving a benefit to someone else.4 In a market relationship, when you provide goods or services, you expect to receive cash or bartered goods of similar value in return. In a communal relationship, you are expected to help when there is a need, irrespective of payment. Such relationships are most familiar among family members and friends, who willingly give time and labor without obliging anyone to pay them. Medicine involves both kinds of interactions. It has marketplace elements that are inherent in any business — a physician receives payment for services. But there is also a communal relationship, an expectation and obligation to help when assistance is needed. We believe that in the current environment, the balance has tipped toward market exchanges at the expense of medicine's communal or social dimension.
I agree with this as well. But I'm not sure how to go about fixing it. No matter how much a person may find medicine fascinating, or go into the field for the love of caring for patients, the market pressures will exist. The authors suggest that a "medical home" model may provide an answer, in which insurers pay a fee for enhanced care for their enlistees, meant to cover the unreimbursed time we spend talking about how to wean kids off the bottle, or counseling depressed teenagers, or discussing the risks and benefits of vaccines, etc. This sounds promising, but I'm skeptical that third-party payers will be willing to subsidize this kind of care at the expense of their own bottom lines. (In my experience, insurance companies bend over backwards to avoid paying for care, and this solution seems a bit too much like pie in the sky.) How high are these fees going to be to take the pressure off providers? What if some insurers are willing to pay these additional fees, and others do not? Do we preferentially enroll patients whose insurers offer them, or do we spend more time with the "medical home" patients? (I think the ethical problems with those possibilities are obvious.)

I think universal health care would go a long way toward correcting this problem. Hospitals routinely write off the costs of those who receive care but cannot afford to pay, and this increases the pressure to maximize revenue from those who can. Insuring payment for all patients and services would help. Will it be enough? I don't know. But I think it would be a start.

1 comment:

  1. Healthcare is a different animal than most consumer needs. If I need care, I don't really compare costs; instead, I compare outcomes, and largely ignore the cost. I want the best care, not the most cost-effective care. You correctly point out that money makes the world go round, so how can nationalized insurance help control costs? I think there are several ways.

    One, we can set a 100% estate tax rate until total (Medicare today, FedCare tomorrow) lifetime costs are recouped. No one is denied care based on ability to pay (the insurance aspect) but those who can pay, do pay in the end.

    Two, we can nationalize medical schools. The current system does a terrible job producing enough doctors to meet demand, and a terrible job getting enough primary care docs out there. The normal incentive would be to raise reimbursement until sufficient numbers chose primary care. But if we are going to control costs, we can't do that (at least not without cutting rates for specialized care docs). Let's put the genius of government to work on overhauling medical education. We can use carrots to steer students into needed areas like primary care; no med school tuition if you work in a designated specialty.

    Three, we can use nurse practitioners for more routine preventative and screening duties.

    Forth, why not have the States set up their own plans rather than have only one national plan? We would find out what worked and what didn't faster by having 50 lab experiments running compared to a single experiment.

    I'm sure there are better ideas out there, but obviously any governmental healthcare policy ought to work on supply and how medicine is delivered, not just making things so inconvenient that people consume less healthcare (which seems to be the private insurance motto).