The Seduction of Primary Care

Hey there, big, smart, good-looking doctor….

Are you tired of being snubbed at all the parties?  Are you tired of those mean old specialists having all of the fun?

I have something for you, something that will make you smile.   Just come to me and see what I have for you.  Embrace me and I will take away all of the bad things in your life.  I am what you dream about.  I am what you want.  I am yours if you want me….

Seduce:   verb [ trans. ]

attract (someone) to a belief or into a course of action that is inadvisable or foolhardy : they should not be seduced into thinking that their success ruled out the possibility of a relapse. See note at tempt .

(From the dictionary on my Mac, which I don\’t know how to cite).

If you ever go to a professional meeting for doctors, make sure you spend time on the exhibition floor.  What you see there will tell you a lot about our system and why it is in the shape it is.  Besides physician recruiters, EMR vendors, and drug company booths, the biggest contingent of booths is that of the ancillary service vendors.

\”You can code this as CPT-XYZ and get $200 per procedure!\”

\”This is billable to Medicare under ICD-ABC.DE and it reimburses $300.  That\’s a 90% margin for you!\”

This is an especially strong temptation for primary care doctors, as our main source of income comes from the patient visit – something that is poorly reimbursed.  Just draw a few lab tests, do a few scans, do this, do that, and your income goes up dramatically.  The salespeople (usually attractive women, ironically) will give a passing nod to the medical rationale for these procedures, but the pitch is made on one thing: revenue.

Our practice has succeeded despite the fact that we don\’t do a lot of procedures.  We are in a shrinking minority, and the monthly cash-flow is putting increasing pressure on us to think about \”alternative sources of revenue.\”  Most of my colleagues in private practice have labs, x-ray equipment, or do procedures.  Some do such medically vital services as hair removal.  I haven\’t had the stomach to go that direction…yet.

Who\’s at fault for this?  Is it the doctors, who are seeking profit over what\’s best for the patient?  Is it the vendors, who find loopholes in the reimbursement structure to milk extra dollars out of the system?

If you leave meat on the floor, don\’t be surprised when your dog eats it.

The payment for the E/M codes (the codes used to bill for doctor\’s visits) are low and the payment for CPT codes (the codes used to bill for procedures) are high.  This is how our system is set up (with great thanks to the RUC) and it is one of the main reasons we spend so much money on healthcare.  We aren\’t doing healthcare, we are doing sick care.  Healthcare is prevention, which takes face-to-face encounters with the patient.  It involves talking and listening, and talking and listening are not deemed valuable by our system.  We are paid to do, not to educate or listen.

It takes great resolve to resist this siren\’s call.  A few years ago, we made a deal with one of the other practices in our building to buy a portion of their x-ray equipment.  It seemed to be a good way to make money off of something we do normally in practice.  But a few months into this deal, we realized two things:

  1. We weren\’t ordering enough x-rays to be profitable.  We had established a mindset of ordering x-rays that minimized their use.  It was a nuisance to wait for the reading on an x-ray and it was inconvenient and costly to the patient, so we made most of our judgments based on something else: the physical exam.
  2. We were ordering a lot more x-rays than we had before.  Instead of trying to find reasons to not order x-rays, we were now financially motivated to order them.  So if someone hurt their ankle, we were much more likely to order one.  If someone had a chronic cough, we were much more likely to order a chest x-ray.  The change wasn\’t that we were hungry for profit, it was just that we were suddenly 180 degrees from our previous mindset: we were trying to find medical justification to order more x-rays.  It was incredibly seductive.

We did back out of the deal, feeling that the care we gave wasn\’t better and not liking the fact that we were losing money.  But would we have backed out if our practice wasn\’t already financially stable?  We are a well-run practice that has been successful despite our non-reliance on procedures, but what of the other practices out there that aren\’t so successful?

One of my favorite sayings is: your system is perfectly designed to yield the outcome you are currently getting. Nowhere is this more true than in healthcare.  We have set up a system that encourages consumption.  We pay doctors more to do more.  We pay doctors less to spend time with patients.  We want our doctors to do better care, but we pay them to do worse care.  We want to save money, but we reward those doctors who spend the most.

So why not change?  Why not pay more for E/M codes and less for CPT codes?  Yes, some doctors will abuse this system by running patients through their office and spending little time with them, but at least it will increase availability of doctors to see patients.  There will always be those who take advantage of any system; that shouldn\’t stop change.

I went into medicine to take care of people, not spend their money.  Why can\’t we have a system that doesn\’t force me to decide between the two?

10 thoughts on “The Seduction of Primary Care”

  1. Rock on, Dr. Rob!! We need to treat people, not conditions. The sooner TPTB move to this model, the better, but I’m not gonna hold my breath. There’s too much money in our current model for the profiteers to let it go. Still, there’s always hope, the thing with feathers.

  2. To ponder your query about procedure codes vs. E/M codes…I think it’s a flaw in the underlying system that somehow translates to “procedures are worth more money than cognitive ability” when it comes to physicians. Is it because procedures in general require more resources? Is it a general disdain for things that aren’t new, flashy, and plainly visible? It’s a lot easier to see the potential benefits in a shiny new state-of-the-art piece of OR equipment than it is to see the utility in the skill of the PCP in figuring out how to properly manage a patient’s 3 chronic diseases. Like so many other things in America, it’s all about flash and novelty instead of about substance and long-term utility. Another part of the problem is that procedure codes are often quite specific in what they mean; E/M levels don’t have nearly that specificity, so it’s harder to pin a suitable dollar amount to them. (The key word here is “suitable”.) It’s a sad state of affairs, indeed, when everything in health care comes down to mere numbers and dollar amounts on the page. It’s nice to see that there are still physicians out there with the heart to actually put the “care” back into health care, even when the system is so misdirected. I’d say we’d all be better off if the philosophy shifted back to “patients first, revenue later”, perhaps taking those pesky middle men (aka insurance companies) into a less prominent role. Don’t know how we’d accomplish that, however; our current system is a miserable behemoth of a beast that will require some serious and potentially painful alterations to be of any use to future generations.

  3. As a teacher of E/M, CPT and ICD-9 I like seeing the docs perspective. It doesn’t have to be all about money.

  4. The system is flawed for sure. Do you think it’s more of the norm these days, or is it just “the few who make everyone else look bad” who are focusing on the money rather than the patients?

  5. No. There are a lot of borderline cases and we are all stretched to decide where exactly we draw the line on charges. I think they are leaving candy on the table and telling the kids to stay away. Some docs go way beyond in charging, but why do I have to decide BETWEEN profit and good care?

  6. As you point out, many smaller practices face uncomfortable choices is they want to remain viable or not become a physician employee of some nearby medical behemoth. Of course, you are spot on that if physicians purchase a medical hammer, then patients all seem to look like nails.

  7. California Consumer

    Great article that needs to reach a wide audience by being published somewhere like the NY Times. My gynecologist is guilty of adding equipment to add to her bottom line. She already refuses to belong to any insurance company “lists” so the patients end up paying the entire, high office visit fee of $350 and up. I balked and quit seeing her when she wanted each of my visits (which she schedules every 6 months) to include a sonogram of my uterus (using her brand new equipment). Enough is enough. My GP bought into an imaging service, but it was free-standing and separate from his office. I found the technician to be careless when doing my breast scans and was annoyed that I had been funneled into getting my breast checkup there. I still see the GP, but went back to my original breast scan location. My endocrinologist’s staff tries to bully patients into having their blood-work drawn in his office. He is another one who will not accept insurance, so that meant the entire cost of blood-work was coming out of my pocket at an excessively high rate. I complained and they allowed me to get a work order t have it done by a facility that takes my insurance which costs me a lot less, though the doctor undoubtedly loses. When doctors start worrying too much about the bottom line it affects patients costs, not just insurance companies.

  8. If the NY Times wants to print it, I won’t object. I promise. I think your examples are indicative of the whole problem. I don’t think doctors should gouge patients, but setting the system up in a way that encourages them to do so is really the main problem. We get what we pay for.

  9. Yes, but the consequences of being a hospital employee are not any better. The problem is that hospitals are cost centers, and doctors are not racking up money for themselves, but instead for their employer. It’s the same problem on a much bigger scale (except that with hospitals, raising E/M won’t do anything to fix the problem).

  10. The current system is the direct result of physicians being smart enough to do what they are given financial incentive to do. If I see a patient who needs a minor procedure, say an endometrial biopsy at the time of a visit I can often do it right while they are in the office. The problem is that if I do that, I know I’ll be reimbursed far less than if I ask the patient to schedule a separate visit for the procedure. Option 1: make patient happy- do it now- no extra time off work or travel. I earn less. Option 2: reschedule, inconvenience patient, create more work. I earn more. It shouldn’t be like that. We should have a system that lends financial incentive to do the right thing.Same goes with all the procedures mentioned. The problem we faced in the 1990’s with capitated care is that primary physicians were asked to shoulder risk for more than just their own services, not given enough information to manage care well, and so we were at insurers mercy. They sell “insurance” and pass the risk off to physicians yet keep the margin. That’s good business when you can get it.
    Finding the right system will take true innovation, may not save anything in the short term, and remains to be defined. I’m only optomistis that I’ll be retired before it happens.

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