Saturday, July 25, 2009

Thoughts re the Future of Single-Payer Medicine

I thought it might be useful to write down my observations and thoughts about the financial side of the practice of medicine, based upon 25 years of private and academic practice of internal medicine, 15 years with a partner, and the last 10 years solo.

First, I have been solo for the past 10 years, because no recent medical school graduate wants to practice (and I have a big-city practice and attend at a medical school) pure internal medicine without an enormous salary guarantee that only a large group can afford to offer (which includes fronting their malpractice insurance). The reason is that HMO's and MCR both pay much more for doing than for thinking and diagnosing, since the powers that pay can measure doing, but not thinking. It is ridiculous that MCR pays me more for a 5-minute rigid sigmoidoscopy than for a 15-minute intake interview. This is why dermatology is the most popular residency. Getting paid $500 for a Botox injection every 3 months is an annuity! And since no insurance pays for it, the physicians can charge whatever they wish. Man is an economic animal, and often will respond to economic stimuli. So when Massachusetts established state-wide health care, there were not enough primary care doctors, and the average wait for a new doctor was 60 days. Just imagine the shortage when the 45 million currently uninsured patients look for a new primary care doctor. We will need at least 10,000 new primary care doctors, and where will they come from? Actually, every doctor should do Botox and Restalen injections and skin biopsies one day a week, so he/she can practice the medicine they like the other four days. And since MCR pays psychiatrists less than they pay me for the same amount of office time, why would any psychiatrist ever want to see a new MCR patient?

Second, we have socialized medicine now, and it's called Medicare. Few MCR patients want to give it up. There are many advantages to the patient, and the main advantage to the physician is that we spend less time on paperwork, and time is our least fungible resource. For a MCR patient, unlike an HMO patient, I don't have to call anyone for permission to get an MRI,and I don't have to worry that the best shoulder surgeon I know is a Cigna MD, and my patient is an Oxford patient, so my patient can't get to see the physician I prefer. I don't have to ask the patient to fax me a list of the HMO ophthalmologists so I can see if I know anyone on the list.
Also, MCR patients get back 5 to 10 times the dollar amount in medical services of the MCR premiums they paid.The tobacco companies showed (but dropped the argument because it made for poor PR) that the government saves money on every patient who dies before reaching MCR age. I also (I hope) will not have to spend time asking someone for permission to prescribe a brand name rather than a generic drug, or to prescribe a brand name drug that is not on their formulary.

Third, if everyone has a private MD, they will "crash" in the ER less often with diabetes out of control, unstable angina, end stage renal disease, etc. If you look at ER visits in Canada vs. here, there are fewer (percentage-wise) visits for acute medical conditions. Having a private physician who you can visit regularly puts a basic floor under your medical condition, even if nothing more is done than blood pressure check, PAP smear, and stool for blood. Overall, since ER visits are extremely expensive because ER doctors do every test they can think of, since they don't want to miss anything (viz. the recent article in the July, 2009 issue of "Archives of Internal Medicine" on the ER workup of syncope in the elderly) we will save a lot of money.

Fourth, technology is expensive, but it works. No patient walks up to an orthopedic surgeon and says "I want a new hip". Instead, the doctor is told "I can't move without agonizing hip pain". No patient says "I need cardiac bypass surgery", or "I need cataract surgery".

Fifth point has to do with malpractice. The most common suit against a family MD is for failure to diagnose a condition. As far as I am aware, no physician ever got sued for doing a test, but only for not doing one. When I started practice,I used to spend 30 minutes to explain to a 40 year old man with no risk factors and atypical chest pain and a normal EKG why he did not need a stress test, and the problems that can result from false positive tests. Now I suggest a stress-echo, stress-thallium and consultation with a cardiologist to the same patient. Why risk being sued even if I know I will win the case? Why spend the time and stress?
As long as we have contingency fees, we will have malpractice cases, and doctors will do extra tests to minimize their exposure, as well as make any referrals any family member of the patient suggests.

Sixth, unless you have a boutique practice, the average MD has to see one patient every 10 minutes, which involves putting 4 patients into 4 rooms, and having the NP or PA take the interval history, do the vital signs, etc. No one can get proper medical care under these conditions. I was trained to spend 15-45 minutes in the office with my patient to take a history and discuss any family stresses, then examine the patient in the exam room, and then bring the patient back into my office to discuss the results. I don't know of any doctor under 60 who practices medicine in this way, and most patients don't know what they are missing.

Seventh, there is something very wrong with the practice of medicine when the majority of doctors advise their children not to go into medicine.

Eighth, every medical system in every country rations by money, time, or availability, since the demand for medical care is almost infinite. England NHS does not transplant kidneys over a certain age, so those who can afford it fly to India to buy a kidney. Some drugs are not allowed in England because the NHS pays for all drugs, and this is how the country caps pharmacy expenses. Canada rations hospitals as to how many open-heart surgeries they can do in a given month. Germany reduces the physicians state-paid salary if their patients' prescriptions cost too much. MCR pays for only so many physical therapy visits or hospital days a year.

Ninth, I still love the practice of medicine, and intend to see my patients as long as I am able.

P.S.: About 10 years ago, there was an article published in NEJM that showed that New Haven had 5 times as many cholecystectomies per capita as did Boston, while Boston had 5 times as many CABG's per capita as did New Haven. Did one city have too many operations, or did the other have too few? No one could determine the answer.

P.P.S. The best review of the current state of internal medicine was published by David. D. Norenberg, M.D., in the Annals of Internal Medicine(Ann. Int. Med. 2009; 150:725-726) accessible at "The Demise or Primary Care". Please read it and share it with everyone you know, physicians, patients, and politicians.

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