Lawmakers and the public in general have no idea how the business and practice of medicine operates. None. When you read statements from many representatives, you see such simplistic, anhistoric thinking that pessimism about health care reform is the only logical response.
Or so it seems from media reports. The New York Times, whose quality seems to be dropping by the femtosecond, reported this week on salaried vs. traditionally paid physicians. This could have been a terrific article, if the reporter knew anything.
Let me catch you up a bit. Doctors are generally paid in one of two ways. They are either salaried employees of a health care system, or they are on their own, billing insurers and patients for the services they provide. For the latter, it is not precisely true, as the Times reports, that, "the more procedures and tests they order, the more money they pocket."
My perspective on this is pretty intimate, as I have two jobs; one in which I'm salaried, the other in which I'm a traditional fee-for-service private practice doc. In my private practice, I am paid a modest fee for seeing a patient. If I order one of the few tests I offer in my office, such as an EKG or a chest X-ray, I can bill for that as well. But the fees are pretty much set. Medicare decides what "fair" reimbursement is, and the rest of the insurers follow suit. If my rent goes up, I cannot raise my fees. If I want my patient to get more procedures or more tests, I can't profit from it, although I could if I owned big, fancy machines. Doctors who own their own stress test machines, etc, can make more money, so that incentive is certainly there. But for the average primary care physician, there is no incentive to "do lots of more". The only incentive built into the system is to see lots of patients so that you can pay the rent.
In salaried models, even though an individual physician might not profit from ordering more stress tests, the system as a whole might, and it wouldn't be unusual for a large health care employer to let its doctors know it. If I work for hospital A, but send my tests to hospital B, I'm robbing myself; from there it's a short walk to thinking that ordering even more tests from hospital A must be a good thing.
Of course, the more centralized things are, the easier costs would be to control, and there are certain advantages to unified, campus-based health systems like Mayo, but some of these are overstated. From the TImes:
Michelle Griffiths, 41, of Edmeston found a lump on her breast six years ago. During cancer care at Bassett, Ms. Griffiths's appointments to see her oncologist and primary care doctor are often scheduled on the same day. One doctor will sometimes accompany her during a procedure performed by another, and each has her complete medical history.
"The communication amongst all of my doctors is impressive," said Ms. Griffiths, who works as a database administrator for the insurance company New York Central Mutual. "They always call each other or shoot each other e-mails."
From my own private practice, a small but hardly unique anecdote:
One day, a patient came to me with a lump on his neck. I was rather concerned, and phoned up an oncologist and an ENT while the patient was sitting in my exam room. In minutes, I had set up appointments with both, relevant tests, and by the next week, he had started therapy for his cancer.
While this process may or may not be easier at Mayo or Cleveland Clinic, it's not unique to them.
Changing our system to encourage employment of physicians is an enormous undertaking. If we are to consider it, we had better make sure it's really a good idea. How could we possibly encourage tens of thousands of independent physicians to suddenly become employees, or struggling hospitals to find money to pay them? Philosophically, though, we have to remember where we've come from.
The Flexner Report on medicine in America was released 100 years ago, and was a damning document, highlighting the primitive, disjointed state of American medical education. According to the times, "Abraham Flexner wrote a landmark report that argued teaching hospitals should be staffed only with salaried doctors." This imprecision is unfortunate. What Flexner found was that most medical schools were owned by doctors whose income depended on tuition. This model encouraged them to admit as many students as possible regardless of quality or qualification. Flexner recommended scrapping this model of medical education, and folding medical schools into existing universities. He recommended paying medical professors not through tuition receipts but by salary to help accomplish this. This may seem like a subtle distinction, but what was accomplished was the professionalization of medical education.
Most people don't know how the American health care system works, including our lawmakers. This ignorance is going to get us in some deep trouble, and so far I've seen nothing to assuage my pessimism about health care reform.