Can I Play?

I feel like a little kid standing and watching some bigger kids having fun.
\”Hey guys!  Can I play too?\”

I am talking, of course, about Shadowfax and Ezra Klein.  The big boys are having it out:

Ezra: (Responding to whines about losing money on Medicare):  You don\’t like what Medicare pays?  Why not just dump it?  You guys aren\’t dumb.  If Medicare was so bad, docs would just leave!  It\’s a free country, you know!

Shadowfax: (Disappointed in such words by someone he respects):  You knuckle head!  We can\’t just dump it!  Some docs make lots of moolah off of Medicare (those big ortho oxes, for one), but a lot of us don\’t have a choice and it\’s killing us!

Ezra: (Amused that Shadowfax should challenge him and using the word \”wonky\” in the process):  What a goof you are!  Show me the law that says you have to accept Medicare.  Yeah, some docs take it on the chin, but hey, life\’s not always fair.  Besides, those dopey hospitals you work for are not loosing their shirts.  The more they are paid, the less efficient they are.  Get a brain, horsey boy!

Shadowfax: (Frustrated, but enjoying the thrill of battle – and making reference to Mike Dukakis in the process):  Were you listening to me??  I was talking about doctors, not hospitals!  Yeah, some hospitals may be doing well, but others are sucking wind.  If they go, we go; and if we go, they go.  And don\’t call me horsey boy!

Ezra: Horsey boy, horsey boy!

Shadowfax: My horsey could beat your…uh…Ezra any time!

Wow.  That looks like a lot of fun!  Can I play?

Here are some points I would make to both of them:

• There is no law that says that we have to accept Medicare, but many of us are afraid that the more the government gets involved, the more likely we will be forced into it.  We are fighting the battle on the front-end, rather than wait until we get an unpleasant piece of legislation passed.  If Medicare/Medicaid cuts reimbursement and docs opt out in droves, the nuclear weapon the government holds is this: they are the ones who let us practice medicine in the first place.  They give us our licenses and can add acceptance of public payers as a requirement.  They could close us down.  It may sound alarmist, but it is a fear of many docs.
• Shadowfax rightly gives the reasons why I couldn\’t opt out of Medicare:
  • It\’s a large part of my practice that I care about and feel responsible to care for.  It isn\’t just about the money, that\’s for sure.  I couldn\’t afford to have a practice that relied on the public payers.  Giving them a larger chunk of my business makes me very nervous.
  • If I opt out, it would force me to be out for two years before I could opt back in.  Medicare has a \”poke you in the eye\” policy that no other insurance plan has: a rule that seems vindictive about anyone who should question their payments.
• Ezra rightly points out the obvious: paying hospitals more would simply pay them more.  It gives them no incentive to become more efficient, and inefficiency is one of the great leaks in the dam that is threatening to do us in.
• This points out the great divide in medicine: hospital-oriented care and hospital-avoiding care.  Like it or not, ED physicians (Like Horsey Boy Shadowfax), hospitalists, many surgeons, and interventional cardiologists are dependent on the hospitals staying busy.  More hospital business means more procedures, and more procedures means more docs needed to do procedures.  The hospitals are definitely not best friends with these docs, as the contract negotiations are usually about who gets the bigger part of the inpatient pie, but they are at least symbiotic.  The success of one generally means the success of the other.
• Primary care and outpatient specialists, on the other hand, are in a totally different situation.  If I am successful, I keep my patients out of the hospital and have them use as few resources as possible.  Our system may give me perverse incentives to do more procedures (which is why many PCP\’s in our area are becoming hospitalists), but most of us PCP\’s are trying to keep our patients from needing hospitalizations, endoscopies, cardiac interventions, surgery, and visits to the ED.  In short, my success would be bad news to hospitals and procedure-based specialists.  Hospitals need me for a referral source, but don\’t really want me doing my job well.

It all comes down to dividing up the pie.  There is no win-win scenario here; primary care is fighting for money that hospitals and procedural specialists have gotten in the past.  The more our success, the harder life will be for them.  Yes, we could ramp down payments to hospitals through lower reimbursement rates (as Ezra suggests), or we could just encourage the success of primary care which would accomplish the same thing in a much more rational fashion.

The thing that I find interesting is that this argument is a microcosm of the whole healthcare debate.  Look who is discussing this issue: a person in Washington and a specialty physician.  I mean that with absolutely no disrespect to Mr. Klein and Dr. Fax – I think they are both much more rational in their arguments than many of the voices of people in power.  But isn\’t it ironic how primary care is spoken of in the third-person all the time?  Washington concedes that we are important, and many specialists are quick to use us as a reason to not cut healthcare reimbursement, but we are seldom really at the table making the arguments.

Someday we need to be invited to play.  I\’d even be OK with being called \”Llama Boy.\”