Shift from fee-for-service proposed

There is no doubt that the exponentially rising cost of medical care is not sustainable. Currently, nearly 3 trillion dollars annually, or roughly 18% of the GDP, is spent on health care. I’m not sure the percent being spent currently in and of itself is intolerable, but the trend of accelerating cost increase shows no sign of abating, and we will inevitably reach some crisis point soon. There are obviously several drivers for health care cost, physician payment being one of the larger components. U.S. physician salaries, interestingly, are among the lowest among western nations, accounting for 8.6% of health care dollars annually, with only Sweden devoting a lower amount at 8.5%.

First, I would say that I have no objection to consideration of physician payment reform if it is part of an overall plan where all parties have some skin in the game, including payments for technology, pharmaceuticals, hospitals, insurers, etc. Second, if we Americans spend so much on health care yet U.S. physicians take home such a comparatively small amount, perhaps their costs outside of their salaries are too high, such as outrageous education costs resulting in massive student loan repayments or sky-high malpractice insurance premiums. Now that I have alienated lawyers, insurers, educational institutions and large corporations with my global perspective, let me drill down into some specific details of this report.

The "National Commission on Physician Payment Reform" sounds like some federal government generated project, but is in fact the handiwork of the Society of General Internal Medicine. As you might expect from its name, this is a society of "more than 3,000 academic generalists," according to the information on its website. It strikes me as an inherently biased setup when a group of generalists decides that specialists who do procedures are being paid excessively and therefore the rules of physician reimbursement must change. Not every recommendation seems off base. For example it seems appropriate to couple fee-for-service with outcomes metrics into contracts, but we all know how challenging it is to get meaningful outcome measures.

Some recommendations have consequences that would seem to potentially worsen the problem the commission is trying to solve, such as repeal of the SGR. Most of the recommendations, however, are simply a direct assault on payments to proceduralists. This includes freezing procedure payments at current rates for 3 years while increasing payment for E&M codes. Or "recalibrating fee-for-service payments to ... penalize behavior that overuses care," whatever that means and to be determined by whom? The full list of recommendations is available online. The list of commissioners was equally interesting, since it appears as though the panel’s conclusions were pre-ordained based on their prior occupations, appointments, or publications. My takeaway impression of their overall message was "there is too much money being spent on health care overall and physicians specifically, so give more of it to internists and we will spend it better."

We, as a country, must begin to make some difficult decisions as to how to spend our limited resources. I suspect my surgical colleagues are willing to shoulder their fair share of the cost-cutting pain, but we cannot be the only group asked to shoulder this burden. All the parties involved should be prepared to make concessions, including patients, physicians of all types, and payers.

Dr. Brian Rubin is a professor of surgery at Washington University in St. Louis and an associate medical editor for Vascular Specialist.

There is no doubt that the exponentially rising cost of medical care is not sustainable. Currently, nearly 3 trillion dollars annually, or roughly 18% of the GDP, is spent on health care. I’m not sure the percent being spent currently in and of itself is intolerable, but the trend of accelerating cost increase shows no sign of abating, and we will inevitably reach some crisis point soon. There are obviously several drivers for health care cost, physician payment being one of the larger components. U.S. physician salaries, interestingly, are among the lowest among western nations, accounting for 8.6% of health care dollars annually, with only Sweden devoting a lower amount at 8.5%.

First, I would say that I have no objection to consideration of physician payment reform if it is part of an overall plan where all parties have some skin in the game, including payments for technology, pharmaceuticals, hospitals, insurers, etc. Second, if we Americans spend so much on health care yet U.S. physicians take home such a comparatively small amount, perhaps their costs outside of their salaries are too high, such as outrageous education costs resulting in massive student loan repayments or sky-high malpractice insurance premiums. Now that I have alienated lawyers, insurers, educational institutions and large corporations with my global perspective, let me drill down into some specific details of this report.

The "National Commission on Physician Payment Reform" sounds like some federal government generated project, but is in fact the handiwork of the Society of General Internal Medicine. As you might expect from its name, this is a society of "more than 3,000 academic generalists," according to the information on its website. It strikes me as an inherently biased setup when a group of generalists decides that specialists who do procedures are being paid excessively and therefore the rules of physician reimbursement must change. Not every recommendation seems off base. For example it seems appropriate to couple fee-for-service with outcomes metrics into contracts, but we all know how challenging it is to get meaningful outcome measures.

Some recommendations have consequences that would seem to potentially worsen the problem the commission is trying to solve, such as repeal of the SGR. Most of the recommendations, however, are simply a direct assault on payments to proceduralists. This includes freezing procedure payments at current rates for 3 years while increasing payment for E&M codes. Or "recalibrating fee-for-service payments to ... penalize behavior that overuses care," whatever that means and to be determined by whom? The full list of recommendations is available online. The list of commissioners was equally interesting, since it appears as though the panel’s conclusions were pre-ordained based on their prior occupations, appointments, or publications. My takeaway impression of their overall message was "there is too much money being spent on health care overall and physicians specifically, so give more of it to internists and we will spend it better."

We, as a country, must begin to make some difficult decisions as to how to spend our limited resources. I suspect my surgical colleagues are willing to shoulder their fair share of the cost-cutting pain, but we cannot be the only group asked to shoulder this burden. All the parties involved should be prepared to make concessions, including patients, physicians of all types, and payers.

Dr. Brian Rubin is a professor of surgery at Washington University in St. Louis and an associate medical editor for Vascular Specialist.

There is no doubt that the exponentially rising cost of medical care is not sustainable. Currently, nearly 3 trillion dollars annually, or roughly 18% of the GDP, is spent on health care. I’m not sure the percent being spent currently in and of itself is intolerable, but the trend of accelerating cost increase shows no sign of abating, and we will inevitably reach some crisis point soon. There are obviously several drivers for health care cost, physician payment being one of the larger components. U.S. physician salaries, interestingly, are among the lowest among western nations, accounting for 8.6% of health care dollars annually, with only Sweden devoting a lower amount at 8.5%.

First, I would say that I have no objection to consideration of physician payment reform if it is part of an overall plan where all parties have some skin in the game, including payments for technology, pharmaceuticals, hospitals, insurers, etc. Second, if we Americans spend so much on health care yet U.S. physicians take home such a comparatively small amount, perhaps their costs outside of their salaries are too high, such as outrageous education costs resulting in massive student loan repayments or sky-high malpractice insurance premiums. Now that I have alienated lawyers, insurers, educational institutions and large corporations with my global perspective, let me drill down into some specific details of this report.

The "National Commission on Physician Payment Reform" sounds like some federal government generated project, but is in fact the handiwork of the Society of General Internal Medicine. As you might expect from its name, this is a society of "more than 3,000 academic generalists," according to the information on its website. It strikes me as an inherently biased setup when a group of generalists decides that specialists who do procedures are being paid excessively and therefore the rules of physician reimbursement must change. Not every recommendation seems off base. For example it seems appropriate to couple fee-for-service with outcomes metrics into contracts, but we all know how challenging it is to get meaningful outcome measures.

Some recommendations have consequences that would seem to potentially worsen the problem the commission is trying to solve, such as repeal of the SGR. Most of the recommendations, however, are simply a direct assault on payments to proceduralists. This includes freezing procedure payments at current rates for 3 years while increasing payment for E&M codes. Or "recalibrating fee-for-service payments to ... penalize behavior that overuses care," whatever that means and to be determined by whom? The full list of recommendations is available online. The list of commissioners was equally interesting, since it appears as though the panel’s conclusions were pre-ordained based on their prior occupations, appointments, or publications. My takeaway impression of their overall message was "there is too much money being spent on health care overall and physicians specifically, so give more of it to internists and we will spend it better."

We, as a country, must begin to make some difficult decisions as to how to spend our limited resources. I suspect my surgical colleagues are willing to shoulder their fair share of the cost-cutting pain, but we cannot be the only group asked to shoulder this burden. All the parties involved should be prepared to make concessions, including patients, physicians of all types, and payers.

Dr. Brian Rubin is a professor of surgery at Washington University in St. Louis and an associate medical editor for Vascular Specialist.