The vast amounts spent globally on health care do not seem to translate into access for many patients, quality care, and improved outcomes. The US, in particular, spends large amounts, now more than $2 trillion a year, without getting universal access, or superb quality and outcomes. While we spend all this money, the primary care and generalist practitioners on the front lines of care are paid less and less, are increasingly embattled and disgruntled, and their numbers are rapidly thinning.

Although these problems are large, there is not much clear discussion of them.

Thus, it was encouraging to see the vaunted New England Journal of Medicine, the premier US journal of medicine, take up the issue of the “future of primary care.” A few weeks ago, the journal published a series of commentaries on the issue,(1-6) and the transcript of a round table discussion among their authors.(7) It was touted as the views of experts on “the crisis in U.S. primary care.”

Unfortunately, even though the series acknowledged some surface characteristics of the US health care system that have lead to this crisis, it didn’t delve further into its causes.

On the surface, a major cause of the crisis is that payments to primary care doctors are so limited that we’re driving them out of business, while we pay lavishly for new, high-technology, often risky and invasive procedures.

However, understanding how and why this happens requires dissecting layer after layer of complex details. Doing so can be frustrating, if not eye glazing, and this might be one reason why the discussion of this pivotal issue has been so limited.

The first layer of complexity was implicitly acknowledged, but not discussed in the NEJM series. Bear with me through it.

The First Layer of Causation: Low Payments for Face-to-Face Visits, Rising Overhead

Doctors are paid for each encounter with a patient. Their pay only covers what they do in the presence of the patient, and not other efforts on patients’ behalf, e.g., communicating with patients when they’re not in the office, communicating with other professionals, paperwork required by insurance companies, etc, etc. Furthermore, pay for office visits is available only in a very small number of categories, and the pay for more complex visits isn’t commensurate with the increase in time and effort that they require, so that physicians who spend a lot of time trying to deal with complex problems won’t be paid commensurate with their work. Pay for office visits has not increased as fast as inflation, and certainly not as fast as the expenses of running doctors’ offices, i.e., office overhead, has increased. Thus, to try to maintain income, and to support increasingly complex office operations and overhead, primary care doctors must limit the time they spend with any one patient.

The result is the 15 minute visit for nearly all patients. But it is ridiculous to try to manage complex problems in 15 minute visits. Furthermore, primary care physicians spend hours of unpaid time doing paperwork, communications, etc.

The NEJM special articles dealt briefly with the contrast between how primary care physicians and proceduralists are paid, and the adverse effects of the 15-minute visit. The series coordinator, Dr Thomas Lee, noted that “procedure-oriented specialties offer higher potential incomes.”(1) Dr Allan H Goroll decried the “current volume-driven, fee-for-service approaches,” the “piecework payment system that perpetuates our ‘hamster-wheel’ environment.”(4) Dr Thomas Bodenheimer asserted that primary care doctors are”overstressed by big patient panels.” He blamed this on “the over-burdened 15-minute clinician visit.”(3) He mentioned the 15-minute visit three other times in his commentary. In the round table discussion that accompanied the articles, he protested, “it’s the tyranny of the 15-minute visit. If you come in to your practice in the morning and you see that you’ve 12 to 15 15-minute visits in the morning and another 12 to 15 15-minute visits in the afternoon, and you know you cannot do it all in 15 minutes….”(7) Finally, in the round table discussion that accompanied the series, Dr Katherine Treadway offered the longest and most impassioned discussion, first explaining the problem,

Since I’ve been in practice a long time and I have an elderly, sick population, that for every hour of face-to-face time, I’ve another hour, at least, of time that I spend that’s unreimbursed. So, if I’m there for 13 hours, I’m getting paid for about 6 of the hours I’m spending.

and

The RVU system is …designed for specialty care and single problems. There is nothing in the RVU system that grants you to consider the fact that you’ve just seen somebody with congestive heart failure, hypertension, hyperlipidemia, coronary disease, renal insufficiency, and diabetes.

Why Are Payments Low for Face-to-Face Visits?

However, none of the commentaries addressed how we got to this pass, or, to continue the analogy above, none dissected the next layer. At best, they seemed to imply that this came about due to the forces of nature or an act of God. For example, in the round table discussion, Dr Lee said,

And I want to go to the payment system next. But do you think — I mean, which comes first, the chicken or the egg? Is it in the water and in the culture, in the educational values? And then the payment system may just reinforce that? Or is it the other way around, the payment system’s where it begins and that’s why it’s in the water?

To which Prof Barabara Starfield could only reply,

Unfortunately, it’s the chicken and the egg cycle. It doesn’t start in any one place.

The Role of the RUC

Actually, one can find the next layer of explanations in one place. The current bizarrely distorted manner in which doctors are paid was the act of people, a few people operating largely in the shadows.

The US Medicare system determines what it pays physicians using the Resource Based Relative Value System (RBRVS). This system determines the pay for every kind of medical encounter according to a complex formula that’s supposed to account for physicians’ time and effort, physicians’ practice expense, and the cost of malpractice insurance. The components of physicians’ effort assessed are, in turn, technical skill and physical effort; the required mental effort and judgment; and stress due to the potential risk to the patient.

To keep the system, which was started in 1990, current, requires addition of new kinds of encounters, which means encounters involving new kinds of procedures, and updating of the estimates of various components, including physicians’ time and effort. To do so, the Center for Medicare and Medicaid Services (CMS) relies nearly exclusively on the advice of the RBRVS Update Committee (RUC). The RUC is a private committee of the AMA, touted as an “expert panel” that takes advantage of the organization’s First Amendment rights to petition the government. Membership on the RUC is allotted to represent specialty societies, so that the vast majority of the members represent specialties that do procedures and focus on costly, high-technology tests and treatments. However, the identities of RUC members are secret, as are the proceedings of the group.

This opaque and unaccountable process has resulted in increases outstripping inflation in fees paid for procedures, while fees paid for “cognitive”medicine, i.e., for primary care, and for services that involve diagnosis, management of acute and chronic disease, counseling, coordination of care, etc, but not procedures, have lagged inflation. The effects of the RUC have been amplified by the unexplained tendency of commercial managed care and health insurance to track the RBRVS system when making their own payments to doctors.

For further details about the RUC, see these posts on Health Care Renewal (here, here, here, and here) and important articles by Bodenheimer et al,(8) and Goodson.(9)

The Unanswered Questions

Understanding this layer of the process raises some major questions, whose answers could help dissect the next layers.

• How did the government come to fix the payments doctors receive? Government price-fixing has not been popular in the US, yet this has caused no outcry.
• Why is the process by which they are fixed allowed to be so opaque and unaccountable? Why are there no public hearings on the updates, and why is there no input from practicing doctors or organizations other than the RUC?
• How did the RUC become de facto in charge of this process?
• Why does the AMA keep the membership on the RUC secret, and give no input into the RUC process to its general membership?
• Why is the RUC membership so dominated by procedural specialists? Why were primary care physicians, who made up at least a sizable minority of doctors when the update process was started, not represented according to their numbers?
• Why has there been so little discussion of the RUC and its responsibility for an extremely expensive health care system dominated by high-technology, high-priced, risky and invasive procedures?

Of course, since the NEJM series failed to address the role of the RUC in the collapse of primary care, it couldn’t raise, much less start to answer such questions. The series mentioned the RUC only once, and virtually parenthetically, (by Dr Gorroll, who noted, “the current system “relies on the Relative Value Scale Update Committee [RUC] of the American Medical Association to set values for primary care services, despite the committee’s marked overweighting in favor of procedural specialties….”[4]) Despite having written a key article explaining the role of the RUC,(8) Dr Bodenheimer was apparently only asked to write about practice innovations that could somehow compensate for continuing limits on the length of primary care visits.(3) It appears that it remains politically incorrect to question the RUC.

However, failing to comprehend, or even address the causes of the collapse of primary care will make it all the more difficult to find a way to revive it.

“Those who cannot remember the past are condemned to repeat it.” attributed to George Santayana

References

1. Lee TH. The future of primary care: the need for reinvention. N Engl J Med 2008; 359: 2085-2086. Link here.
2. Treadway K. The future of primary care: sustaining relationships. N Engl J Med 2008; 359: 2086, 2088. Link here.
3. Bodenheimer T. The future of primary care: transforming practice. N Engl J Med 2008; 359: 2086, 2089. Link here.
4. Goroll AH. The future of primary care: reforming physician payment. N Engl J Med 2008; 359: 2087, 2090. Link here.
5. Starfield B. The future of primary care: refocusing the system. N Engl J Med 2008; 359: 2087, 2091. Link here.
6. Roland M. The future of primary care: lessons from the U.K. N Engl J Med 2008; 359: 2087, 2092. Link here.
7. Lee TH, Treadway K, Bodenheimer T, Starfield B, Goroll A. The future of primary care: perspective roundtable: redesigning primary care. Link here.
8. Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap: why it matters. Ann Intern Med 2007; 146: 301-306. Link here.
9. Goodson JD. Unintended consequences of Resource-Based Relative Value Scale reimbursement. JAMA 2007; 298(19):2308-2310. Link here.

[Source : Health Care Renewal]

At an article this day entitled “Medtronic States Device for Spine Faces Probe” (Wall St. Journal, Nov. 19, 2008, subscription required) the WSJ reports another major medical device manufacturer, Medtronic, faces a probe for promoting unapproved uses of its technologies, which is improper:

Physicians can deploy FDA-approved drugs and products any way they see fit, but companies aren’t permitted to promote off-label applications or to pay doctors inducements to do so.

“While the law establishes that doctors can prescribe any approved treatment, but off-label promotion by manufacturers is not granted, there’s growing concern that the line is being crossed, and a Justice Department review is the right kind of response to those questions,” said Sen. Charles Grassley (R., Iowa) who has been looking into whether inducements by Medtronic have led physicians to use its products off-label.

This type of story is usual at Healthcare Renewal, and the blog leaves quite a rich trail of search engine-available information, since the healthcare blogs are relatively immune to the anechoic effect. I see numerous hits from governmental agencies in the U.S. and overseas, for example, on search engine queries regarding malfeasance or incompetence at specific companies and organizations. I will not comment on the ethics of the Medtronic/nonapproved promotion issue any further here.

I do want to comment, however, on an item in the WSJ article that caught my eye:

Depositions in a malpractice lawsuit brought by Laurie DeNeui, of Rushmore, Minn., focused on off-label Infuse use and Medtronic salesman Curt Messler’s relationship to her spinal surgeon, Bryan J. Wellman of Sioux Falls, S.D. Mr. Messler said in his depositions in the case that he was with Dr. Wellman in the operating room “a lot” when he used Infuse. He also stated he considered Dr. Wellman a friend and stated the men saw each other socially.

… About four days after her October 2005 operation to fuse cervical vertebrae, Ms. DeNeui stated in an interview, her neck swelled up, she had trouble swallowing and she started choking on food. Soon, she said, she started having difficulty breathing. Ms, DeNeui, 46, stated the problems prevented her from returning to work as a instructor and baffled several specialists. Steroid treatment helped ease the breathing and gagging problems, but caused her to gain weight and contract diabetes.

Dr. Wellman denies any malpractice. In a deposition, he stated Mr. Messler encouraged him to use Infuse in cervical spine operations, and that he has done more than 100 such procedures with the product. Dr. Wellman said he discussed with Mr. Messler the right dosage of the Infuse material to use in the surgeries but determined the dosage on his own.

Mr. Messler, who isn’t a physician, has a degree in criminal justice, and his prior work history included owning a bar and jobs with New York Life Insurance Co. and Procter & Gamble Co. In his depositions, Mr. Messler denied encouraging Dr. Wellman to use Infuse for unapproved applications or discussing how much to use.

This is the typical I stated-he stated scenario. That issue’s adjudication will also not be discussed here. While the article also states this patient signed a consent to permit Medtronic representatives to be in the operating room, I have several questions of a very fundamental nature.

In background to these questions, when I was fifteen years old I attended the summer NSF-funded Advanced Preceptorship Training Program (ATP) at Hahnemann Medical College and Hospital back in the early 1970’s. It was a program designed to introduce high school students to biomedicine (ironically Hahnemann’s former medical college is now part of Drexel University, where I teach healthcare informatics). I was assigned back then to watch surgery under the surgical team of Drs. Pearce, Ulin and Weinstein, permitted to scrub in and hold retractors, and in one case to actually saw through a femur in a leg amputation for diabetes-related gangrene. I also made rounds with the surgical team. While this day this practice would probably not be permitted on privacy and malpractice concerns, I can honesty admit I offered no advice on surgical procedures or other interventions. I simply didn’t have the background.

In the Medtronics situation of reps in the O.R., I thus ask the following questions:

• Were patients and others in the O.R. aware of the lack of the Medtronic sales representative’s medical credentials?
• Are such consents sought and signed routinely for allowance of medical device company reps in the operating theater?
• What, exactly, was the purpose of having a nonmedical person in the O.R.? What, exactly, could such a person contribute?
• Why would any patient want a nonmedical person in the O.R. with the potential for that person to give advice or affect the procedure in some manner?
• What were patients told to convince them to sign the consent?
• If advice was given of any kind to any clinician the O.R., would that not constitute the practice of medicine without a license?
• What were the rep’s obligations if they witnessed anything they thought could be misuse of the device, or any other practice they thought improper?
• Did the rep follow the surgical team around in postop care?
• Why couldn’t Medtronic actually hire people with medical backgrounds for such roles, instead of a former bar owner and P&G sales rep? Could such people be afforded?
• Might people with medical credentials and experience actually be superior suited to make valid scientific observations in the O.R. setting?

These are just some of the questions that come to mind in the seemingly inexhaustible cornucopia of nonmedical people either leading healthcare organizations or performing roles perhaps superior performed by people who actually have a medical background, and actually know at a very detailed level what they’re doing.

– SS

[Source : Health Care Renewal]

We’ve frequently discussed the plight of the University of Medicine and Dentistry of New Jersey (UMDNJ), the largest health care university in the US. Facing indictment for federal crimes, the university operated under a deferred prosecution agreement and the supervision of a federal monitor from 2005 to 2007. We most recently blogged about UMDNJ here, and see links backward to previous posts from here.

As reported by the Newark Star-Ledger, there have just been criminal convictions in two cases related to the scandals at UMDNJ:

Former senator Wayne R. Bryant was found guilty yesterday of selling his office as one of New Jersey’s most influential lawmakers for a medical school job that padded his pension, in a case that also put on trial the secret political horse-trading of the state budget process.

A federal jury in Trenton convicted Bryant of bribery for soliciting a job at the School of Osteopathic Medicine in Camden County and using his influence to help the school acquire $10.5 million in say grants between 2003 and 2006.

The jury also found Bryant, 61, of Lawnside, guilty of 11 counts of mail and wire fraud stemming from the scheme to land the $35,000-a-year ‘low-work’ job at the school, run by the University of Medicine and Dentistry of New Jersey. Prosecutors stated Bryant used the mail to apply for the job, get paid, and file a financial disclosure form for 2003 that omitted his UMDNJ job — all in an effort to defraud the state Division of Pensions and Benefits.

‘The brazen arrogance of Wayne Bryant — to believe that he was totally beyond the reach of the law, to extort state institutions for personal profit in return for the funding of good and worthwhile programs that serve the poor, the disadvantaged and the needy of our state — is simply the most disgusting conduct I have seen by a public official in my seven years as U.S. attorney,’ [US Attorney Christopher J] Christie stated.

The jurors, who deliberated 14 hours over three days, also convicted the medical school’s former dean R. Michael Gallagher, formerly of Haddonfield, of bribery for hiring Bryant to perform what prosecutors say was a phony community relations job. Gallagher also was found guilty on five of the six mail and wire fraud charges involved with creating the job.

The ex-senator and the ex-dean each face more than 15 years in prison when they’re sentenced March 20, according to the U.S. Attorney’s Office.

The relationship between Bryant and UMDNJ was perhaps made a bit more clear by the Philadelphia Inquirer’s version of the story:

In late 2002, Bryant solicited a job from Stuart Cook, then president of the public University of Medicine and Dentistry of New Jersey (UMDNJ). Prosecutors termed it a ’shakedown.’

Gallagher, the former dean of the School of Osteopathic Medicine in Stratford, then rigged a hiring process to give Bryant a job. The school is one of UMDNJ’s campuses.

During the years of his employment, from 2003 to 2006, Bryant steered $10.5 million to the osteopathic school, and lobbied on its behalf in other matters.

Prosecutors noted that he had done nothing to help the school before going on its payroll.

Bryant was paid a $35,000 salary and given a $5,000 bonus one year. This, prosecutors said, despite the fact that he showed up on campus just one morning a week and spent most of his time there reading the newspaper and talking on the phone.

These were not the first findings of guilt in the UMDNJ case. Earlier this year, as we noted here, two UMDNJ cardiologists pleaded guilty of embezzlement in a scheme in which they were paid for academic work they didn’t do in exchange for referring patients to UMDNJ. However, by that time, nobody in a leadership position in UMDNJ had been charged, much less convicted of a crime in connection with the scandal. Now at least one former UMDNJ official has been convicted.

In a continued and striking demonstration of the anechoic effect, the UMDNJ case up to now has never graced the pages of any medical, health care research, or health care policy journal. I wonder whether the convictions of a prominent politician and a former osteopathic school dean will be enough to get this dramatic and sordid case noticed in the medical and health care literature. One would think that a massive health care university forced to operate under a federal deferred prosecution agreement, under the supervision of a federal monitor, would have sufficient implications about problems in the leadership and governance of health care organizations to gain widespread attention.

However, as long as such cases are reported as merely regional aberrations, physicians, other health care professionals and patients will probably continue to believe that the ethical challenges they might witness are merely local misfortunes. Until we all recognize that the problems are widespread, if not global, we’ll not be moved to action. And maybe that’s why there is such pressure not to discuss the wider implications of local problems, or to discuss how similar all the local problems are.

For discussion of many other cases of poor leadership and governance of health care organizations, please peruse the archives of Health Care Renewal.

[Source : Health Care Renewal]

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