In defense of Robin Cook’s op-ed piece

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Category : Medical Rants

At least 2 bloggers have vigorously attacked Robin Cook’s op-ed piece: Primary Care Prejudice II and Robin Cook Writes Fiction. Both bloggers are family physicians. They focused on this quote:

Ideally, the hourly rate would not be the same for all primary care physicians, but would be assessed on a sliding scale, predicated on a doctor’s level of education. Internists and pediatricians — the primary care doctors who have had the most training — would receive a higher rate than general practitioners and family physicians would.

Medpundit points out that GIM, pediatric and family medicine training all take 3 years. I agree that he erred in this paragraph.

I urge that critics do not throw out the baby with the bath water. Dr. Cook does make an important conceptual point. Our reimbursment system which pays us for seeing a patient regardless of the time it takes leads to perverse incentives. I have previously blogged on this issue in several ways:

Words that I wrote after an airplane discussion with a lawyer still ring true:

The concept of our reimbursement system is bankrupt. If you pay me for a unit of care, regardless of how much time I spend, I will look for ways to decrease the time of that unit of care. If I can see 7 patients in 2 hours rather than 6, I have increased my gross income by 17%, without significantly changing my overhead! But I also had to decrease each patient visit by approximately 3 minutes.

Those 3 minutes matter! They allow the physician to ask a few more questions and answer a few more questions. They improve the doctor patient relationship. Without 3 minutes, we may leave out something important from the visit.

I suspect that the continued undersupply of general internists (and also family physicians) will eventually change our thoughts of reimbursement. I certainly hope so. Every chance I get (and I do get chances) I discuss this concern. We must publicize the problem of generalists in our current reimbursement system.

The lawyer with whom I had this discussion understood perfectly. She understood that shortchanging a client leads to less adequate lawyering. Providing incentives to see patients faster (and make NO mistake – our current system rewards speed over thoroughness) leads to undesirable externalities. We must fight hard to rethink this system.

Many physicians take shortcuts because of the reimbursement system. As I believe strongly that generalists can make the greatest contribution to our country’s health, we desparately need a reimbursement system that provides the appropriate incentives.

Whether the system should be pay by the hour, or a modification of retainer medicine is not clear? What is clear is that the way that we currently reimburse physicians is irrational.

Our Dinosaur friend states:

Back out here in the real world, sure we can opt out of all the contracts. The only problem then is getting patients to come to us if they actually have to — GASP — pay. Unless (or until) all of us do it, there’s always going to be someone up the street they can go to “without” paying (as in, “But doc, they take my insurance.”) Still, things are getting bad enough that more and more of us are contemplating exactly that.

We could all opt out of insurance contracts (however, this will work for a limited number of physicians doing only outpatient work). We could all move to a retainer model.

These choices will certainly work for individuals. If all physicians embraced this model, many patients would have no access to primary care physicians.

I would prefer a system minimizes third party payers. Such a system would give much great transparency and probably decrease the demand for expensive tests, drugs and consultations.

In defense of Robin Cook, he makes explicit the amount of time physicians spend caring for patients outside of the examining room. I personally like his solution, but I do understand those who argue otherwise.

His piece should make everyone think. I believe it an important contribution to what I hope will continue to be an ongoing discussion of appropriate models of reimbursement.

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Comments (3)

Actually, I focused more on the inaccurate statement that insurance pays a flat rate per visit. The paragraph you quoted, while also wrong, wasn’t the meat of my objection. But thanks very much for the mention and linkage.

“if all physicians embraced this model, many patients would have no access to primary care physicians”.

How is that different from today’s model. Many patients today solicit their primary care from ERs. If you are a 23 year old fashion-jewelry store employee without health care insurance, are you going to pay the $120 out of pocket rate that not even the best insurance company pays the docs for an annual?

When you write, “Many physicians take shortcuts because of the reimbursement system,” I question either your accuracy or your professionalism. I don’t take shortcuts, and I’ll bet that you don’t either. Who is taking these shortcuts? Are you reporting these physicians to the medical board? Are you warning their patients? Are you saying that the system is so bad that we physicians have no choice but to do it quick and dirty so we can make a living. Are you channeling CJD?

I also question your claim that “What is clear is that the way that we currently reimburse physicians is irrational.” While some details might be not optimal, the way the system is set up, as a general rule, the more work you do and the more customers (patients) you satisfy, the more money you make, assuming reasonable efficiency. It’s also true, with some exceptions (anesthesiology comes to mind), the longer and harder you train, the more money you can make when you finally get to work. If you are unhappy that as a general internist, you make less money than a cardiologist or surgeon, that is something that you should have considered when you decided not to do a fellowship or surgical residency. None of these details is a closely guarded secret.

Physicians don’t like it when ordinary commercial concerns intrude on the commercial aspects of our practice- I certainly wish that I could get my full fee for every encounter, just as a local bookstore wishes that Barnes and Noble would go away which in turn would be happy to see Amazon.com disappear. It’s not going to happen. We have to learn to live with it or fight back by telling the big insurance companies and Medicare to take a hike. We can’t take their money and expect them to do our bidding.

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