I was brief yesterday – 36 holes of golf walking on the Oregon coast eats up most of the day and all the energy. I expected Matt to disagree. My points:
1. Increase primary care – the data are so strong that more primary care saves money and improves quality that one no longer can credibly debate the point. We probably will make many subspecialists mad when we fix the payment disparities that exist. Are cardiologists going to take their reimbursement frustrations out on primary care residents?. Well let me give everyone a clue, primary care physicians are very frustrated and feel betrayed by their colleagues as the RUC allowed the income disparity to accelerate for 15 years. The bottom line is that primary care does make a difference and saves costs.
2. Malpractice reform – Of course Matt disagrees, but we could decrease overhead (malpractice premiums) that impact costs. We would decrease unnecessary testing. I have written so often on this issue that I should take a poll. I believe Matt’s side would lose about 90-10.
3. Government mandated overhead – we have too many reporting rules that increase our overhead – and go into the payment formulas. We write unnecessary complicated notes only for billing purposes. We have oppressive rules that all hospitals know are unnecessary. Each rule costs money – and you are paying that money.
What about quality? Readers of this blog know that the word quality drives me crazy, because is so non-specific. This editorial might help us understand – Does improving quality of care save money?
As the NHS enters a period of little or no real growth in funding but incessant demand and cost pressures,1 the idea that improving the quality of services, treatment, and care could actually save money is an attractive proposition. But although there is plenty of evidence that poor quality health care and adverse events are costly both for the NHS in financial terms and for patients in terms of health consequences, there is, as a new report reveals, a dearth of evidence of the reverse relation: that improving quality leads to lower costs.2
In a wide ranging literature review for the Health Foundation, John Øvretveit unearths just eight reasonably robust and well researched examples—mainly from the US—where service or clinical change has led to identifiable savings. These include annual savings of $0.7 million from reducing deep surgical wound infection rates and $0.3 million from earlier patient discharge and reductions in delays in dealing with pathology specimens
As Ben Taylor and I focused on in our Archives editorial, we should focus on hospital safety rather than performance measures. Improving safety does save money. I would argue that better diagnosis will get us there.
With no evidence, I would support a reinvention of the medical note. We must get away for the specified number of physical exam and history points, and rather demand notes that make clear what the physician is thinking and what he/she is planning to do for each point – problem oriented SOAP notes.
Finally, we should have one physician in charge of hospitalized patients – and that physician should write all the orders. Too often I see 3, 4 or 5 physicians writing orders – a guaranteed prescription for chaos, lack of safety and excessive test ordering. We need one person (probably a hospitalist) to coordinate the care of complex patients.
That’s it – only 18 holes today. I sure hope naproxen still works.
{ 2 comments… read them below or add one }
As a primary care physician in a high malpractice risk state and despite never being sued, I pay $2,500 a month for malpractice insurance. With a national malpkractice insurance company and national caps, my premium would go down.
I find it inefficient to submit claims to 20 or more insurance companies. For 08 and 09 the copays have gone up to $35, with a massive check of $15-$20 a visit from the insurance company for each visit. Covering outpatient office visits is wasteful.
The AMA makes the CPT codes and lists the bullet points for each level of care. Then Medicare and the insurance companies simply follow AMA billing guidelines. It seems to be a time waster to have to repeat the same office notes on patients every 3-6 months for T2Dm, HTN, and hypercholesterolemia. Update notes and exams would make more sense and save time. In the inpatient world, why do I have to document the same long note with the one or two systems of conerns over and over? Again an update note would make sense. I don’t get paid for the middle of the night hosptial calls or the prior authorizations for meds/studies. As a primary care doctor I spend a lot of time doing paperwork that is paid poorly.
“but we could decrease overhead (malpractice premiums) that impact costs. We would decrease unnecessary testing. I have written so often on this issue that I should take a poll. I believe Matt’s side would lose about 90-10.”
Physicians don’t have the ability to pass on any malpractice savings, so that wouldn’t change the cost of health care in the least. Nor can they even guarantee that health insurers would in fact pass any savings onto them. Nor have you explained how much having these experts, not to mention additional court personnel, etc. for every case would cost the taxpayer. So how you determine that would outweight mythical savings from unnecessary testing (also a number you can’t quantify), I don’t know. Wishes and dreams do not equal savings.
Not to mention CMS has repeatedly said that malpractice costs don’t factor much, if at all, into its reimbursement determination.
” Each rule costs money – and you are paying that money.”
Nice sentiment, but since you offer no specifics on any of these, much less the costs in your own proposal, its impossible to say. It’s a very Obamaesque position you’ve taken – “this will work because I say so, therefore I need say nothing more.”
Hope it works out for you.
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