Wednesday, October 14, 2009

"War on Specialists?": Wall St. Journal defends the status quo!

The Wall St. Journal, October 13, 2009, contains a “Review and Outlook” piece (editorial) titled “The War on Specialists”. The opinion piece decries the way that “ObamaCare” is going to try to save money by reallocating funds from subspecialists to primary care doctors. As an example, they talk about the proposed cuts to some of the “basic tools of heart specialists”, echocardiograms and cardiac catheterizations. They quote American College of Cardiology CEO Jack Lewin, MD, as saying that it will cause a “horrible disruption” that may make senior patients wait days for tests and services, because staff will have to be laid off. (Of course, it could lead to SHORTER waits if the cardiologists do more procedures per day to try to make up that income!) The WSJ correctly points out that the cuts don’t necessarily cut any spending; “…the RVUs merely redistribute it from one medical bucket to another.” That is, the cap on spending on medical care (called the Sustainable Growth Rate, or SGR, which I have previously addressed) would increase primary care doctors’ reimbursements while it cuts those of subspecialists.

But would these predicted disasters actually come to pass? Hard to know; but what we do know is that the reimbursement for subspecialists is many times that of primary care physicians, so much so that it is more and more difficult to convince medical students, graduating with large debt, to enter primary care. The assertions of the WSJ, and Dr. Lewin (who used to be director of Public Health for the state of Hawai’i, and an advocate for the public’s health, before taking this more highly-paid job) are simply assertions. Following the same pattern as the paper I discussed recently by Dr. Cooper (“’Uncomplicated’ Primary Care?”), and others, they ignore data that shows that there needs to be a balance between primary care and subspecialty care in order to achieve the best outcomes in the public’s health, and that the current ratio is way out of balance. I have cited, over and over again, the literature, from many places and many times, that demonstrates this. And is conveniently ignored in this piece, attacking this consistent data as “based on a flimsy survey” that HHS has done and that Secretary Sebelius and budget director Orszag will not discuss with poor Dr. Lewin. Why bother to look at the data when you can simply assert your beliefs?

The WSJ article ignores the fact that much of the care provided by, for example, cardiologists, is excessive; that supply generates demand. The work of the researchers at the Dartmouth Health Atlas show the dramatic differences in costs of care and frequency of expensive procedures by region – often based on the density of subspecialists – without appreciable differences in health outcomes. (Or, when there are differences, that the outcomes are better where there is less use of expensive technology!) It makes the key mistake of conflating “health” with “preventing death”. Of course, we all want to prevent our deaths when we see meaningful life ahead, but the extraordinary expenditures that often prevent death only by weeks, days or hours, would often be better spent on having a sufficient number of primary care doctors to be able to maintain health, control chronic disease, and do preventive care. [1]

“Markets,” the WSJ asserts, “are supposed to determine the composition of the workforce, not a command medical economy run out of Washington.” Perhaps, but the situation that exists today is far from a “free market”. In addition to the almost-unique ability of medical specialists to generate demand based on supply, as discussed above, the simple fact is that it is the “command economy”, not the market, that accounts for the current, inequitable state of reimbursement. The assignment of RVU values grossly overvalues procedures in comparison to time spent with the patient discussing their health, managing medical problems and planning treatment. It is the fact that Medicare (and thus other insurers, whose reimbursements are almost always tied to multiples of Medicare rates) and its current method of reimbursing fee-for-service by RVU values that have created this inequity. What is needed is to correct it, and this cause is not served by blatantly false assertions that it is a free market, rather than a stacked system, that has created the problem.

While Jack Lewin has become an embarrassment to public health, he is doing his job. The WSJ can advocate for “markets” but should not imply that the status quo is a result of the operation of free markets, rather than a reflection of the way the deck is currently stacked. The WSJ provides no service whatever when it tries to make a discussion about what best serves the health needs of the American people a partisan cause. It can disagree with me on the issues, it can even choose to trumpet its disregard for facts, but this is not, and should not be a Democratic / Republican issue. The health of our people is too important.

[1] For example, the most common outpatient medical visit, code 99213, taking about 20-30 minutes, in which I can address multiple chronic health problems as well as preventive services, is valued at 0.92 work RVUs. If I then clean the wax out of the person’s ear, I get another 0.61.


Adam F. said...

I'm really glad that you spoke to the fact that the market for medical care in this country is far from the "free market" that WSJ claims it is. It is true that, in theory, unfettered markets efficiently (though by no means equitably) allocate resources. Yet it seems to me that very, very few real markets (maybe some commodities) satisfy the theoretical assumptions required to achieve this efficiency. When they don't, the situation is commonly referred to as a 'market failure'--the most common examples being monopoly production that inflate prices and negative social externalities (such as pollution from manufacturing).

In the case of medical care--particularly high-cost, high-risk sub-specialty procedures--the underlying cause of this market failure is information asymmetry. That is, your doctor knows a lot more about your health status than you do, and, if you choose not to follow his or her advice, you might die. This means that your doctor has a great deal of power in determining how much you value a procedure, hence the supply-driven demand in much of specialty medicine. Coincidentally, information asymmetry is also the cause of the adverse selection problem that plagues insurance markets (though in that case it operates the other way around--you, in theory, know more about your health status than your insurer). As Don McCanne points out in his most recent quote of the day, this adverse selection will ultimately doom a public option committed to ensuring access to care rather than making profits (the solution here is clear: eliminate the profit motive in health insurance and put everyone, automatically, into a single risk pool--i.e. single-payer).

I'm so tired of the rhetoric about 'free markets', which implies (and falsely claims sound economics as its justification), that simply allowing the market to work will always produce the best results. The reality is that firms will, as they are designed to do, exploit advantages in the presumed 'free' markets to make as much money as they can. This doesn't lead to efficiency. By the way, even if it did, in the case of health care it would mean that only those who could afford the high cost of care would be able to access it. Apparently this is the Republican (and, it seems, 'moderate' Democrat) vision for America. It's not mine.

Unknown said...

Well said. Case in point of how the existing market has served health outcomes in this country:

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