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Why Patients Should Care About Doctors & Money

“Do patients care about how much money their doctors make?”

This is the headline of a recently published KevinMD post, by Trudy Lieberman, and was written in response to the recent NYT coverage of Medicare disclosing payments to individual providers.

Now, I found the NYT story fascinating on many levels, but I’ll admit it hadn’t occurred to me that the main value of this data release is that patients can find out how much their particular doctors are making off of Medicare.

It’s true that the Times’ main angle — that 2% of doctors receive almost a quarter of Medicare’s payments to providers — is disturbing and gripping. Apparently 100 doctors received a total of $610 million in payments. Who wouldn’t be captivated by that statistic. (Bring out the high rollers for a public flogging, or at least a billing investigation!)

But it was other aspects of the Medicare spending data that I think is more important.

The Medicare spending we should be concerned about

Here are the payment figures that really caught my eye:

  • $12 billion spent on outpatient visits in 2012, with average reimbursement of $57 per visit. This is out of a total Medicare spending of $600 billion for the year.
  • $77 billion overall paid to doctors and healthcare providers (Unclear to me whether this is just Part B, or also includes payments to doctors during hospitalizations.)
  • $13.5 billion spent on “commercial entities like clinical laboratories and ambulance services”

Look at that. Outpatient visits are 2% of Medicare spending. And at $57/visit, is it any wonder that primary care for seniors is often woefully inadequate?
We spend more on laboratory services and ambulances than we do on outpatient visits. 
This data makes me a bit mad, because whenever people like me mention that we need more time with older patients, if we are to do the work society needs us to do, other people start telling us that it costs too much money. For instance, it is widely pronounced that primary care physicians need to learn to do more with less. 
We can spend $1 billion/year injecting an expensive medication for macular degeneration (and that was for 143,000 of Medicare’s 47-50 million beneficiaries), but we don’t pay for clinicians to assess caregiver burden and wellbeing. 

Now, it’s true that if we simply increased the reimbursement for Medicare outpatient visits, we likely wouldn’t see much improvement in healthcare for seniors. To seriously improve primary care and outpatient care for seniors requires not only more money, but changing the way money — and patients — flow through the system. (I’d like to see patients and families having a greater say in how their Medicare money is spent; many might prefer home assistance to an extra echocardiogram. Right now we have payor-centered care rather than patient-centered care.)

Still, on the whole these data reveal that Medicare’s investment in outpatient care — and primary care clinicians — is pitiful.

Surely we can afford to redirect some of that Medicare spending into primary care?

What should patients care about, when it comes to doctors & money?

Let’s return to the question of what patients care about, when it comes to doctors and money.
Trudy Lieberman points out that this information — knowing how much an individual doctor was paid by Medicare — seems unlikely to be valued by patients. For instance, it doesn’t help people know which doctors are better (as if it’s easy to get an appointment with the good doctors, but that’s another issue).
This is probably true. But when I read the following, I find myself wincing:

“Still, I keep returning to the question: What will the data do for the average person? Can a person really use it to make decent health decisions?”

Herein lies the rub. No, this data does not really help an individual make decent health decisions about his or her own health.
But what about the process by which we — a collection of individual citizens residing in this country — decide how we will spend our collective health care dollars?
Every week, I have someone ask me how they can find a geriatrician to provide primary care for their elderly loved one.
Every month I have someone ask me why don’t more doctors make housecalls.
The answers to these questions lie in part in the spending data, because money makes the world go round. We spend 2% on outpatient care. We reimburse clinicians much better for doing procedures than for helping older patients with their primary care problems.

If the average person knew this, then perhaps they’d understand why right now it’s so hard to find a doctor to make housecalls, or to discuss prognosis, or to thoughtfully manage pain and other symptoms.

But most people don’t understand this. Getting people to think about how reimbursement affects healthcare is tough because:
  • The average person doesn’t want to think about it as long as he or she is healthy.
  • When sick, the average person just wants the problems fixed.
  • Whether healthy or sick, the average person is unlikely to be interested in understanding the financial underpinnings of our healthcare system. There is little immediate benefit plus it’s a complex thorny topic that easily is politicized.
In my experience, when faced with illness, patients care quite a lot about what kinds of health services and supports are available. But when faced with illness, people are lacking the time and energy to focus on long plays, like advocating for a better primary care system.

I firmly believe that most people would value and appreciate a more robust system of primary care and supportive care for older adults.

But if they don’t know or care that Medicare only spends a piddly 2% on outpatient visits, or that clinicians are strongly incentivized to avoid engaging in substantive primary care work, then it will be hard for them to exert their citizens’ influence in demanding the primary care infrastructure they deserve.

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Comments

  1. Wayne says

    There's an interesting contrast between seniors on Medicare and others on high-deductible insurance plans. One has no incentive to comparison shop for the best value in health care, since everything is covered by Medicare. The other pays out-pocket until they reach their deductible and thus have a strong incentive to shop and question things like doctor fees and salaries.

    While I don't see anything in health reform that raises fees for office visits and agree that is needed, I do see quite a lots to make me optimistic about the future of health care and senior care, based on new competition that will spur innovation, improve care, and drive down prices.

    It starts with private insurers who can no longer cherry-pick the healthiest customers and deny care once someone's condition becomes expensive. Private payers must now spend at least 80% of premiums on actual medical care, rather than marketing, administrative overhead, and executive salaries, meaning they need new ways to protect profits. Offering low-cost policies with high deductibles is one approach since it protects customers for catastrophic financial burdens while giving them the incentive to shop. And to give the the tools to shop, payers are pressuring providers to transparently disclose once-secret charges up front. They're also starting to pay for things like telehealth video consultations, home health care, and even medical tourism, as long as the outcome is better and cost cheaper. This is putting competitive pressure on providers and should help reduce costs overall.

    There still seems to be an issue with ultra-high costs of some drugs, equipment, and tests, but I expect even them to come down with time, thanks largely to the effects of Moore's Law and devices like the Alivecor ($199) ECG iPhone attachment and Scanadu Scout tricorder. Much of the role of general practitioner will move down-market to the PA, NP, RN, LVN, aide or tech, and even to the consumers themselves.

    These trends may happen first among younger consumers, given their interest in fitness, wellness, quantified self, nutrition, and organics, and the fact that they are the ones buying the high-deductible policies; but seniors on Medicare should benefit too.

    • Leslie Kernisan says

      Thanks for this comment.

      There certainly is a generation of patients who are used to having more say (due to having more skin) in how money is spent on their healthcare. As they age into Medicare, should be interesting to see if they can provoke more of the changes you describe.