Discussion Forum

The September 24 New England Journal of Medicine contains two perspective articles that lay the blame for health care costs solidly in the laps of physicians. In a recitation of a mantra he has chanted since leaving the editorship of the journal, Arnold Relman, M.D., blames the perverse incentives of the fee-for-service payment system for rising medical costs and suggests that the American healthcare system will be rescued by being Mayo-ized (see “Doctors as the Key to Health Care Reform”). Group physicians in large multispecialty organizations with an emphasis on quality and pay them salaries which aren’t tied to what they produce and costs will be controlled, says Relman. The second article, “Getting Past Denial—The High Cost of Health Care in the United States,” from the Dartmouth Institute for Health, which for decades has conducted studies of regional variation of health costs, supports Relman’s contention, suggesting that 70 percent of the large variations in health costs are caused by “discriminatory decisions by physicians “ unrelated to patient income or level of health.

So, physicians, ask yourself: are you the cause of the healthcare crisis? Do you order more tests and procedures because it makes you more money? And if you don’t, do you know other physicians who do? If so, what would change this?

—Charles R. Meyer, M.D.

Intriguing comments. Let me add corollary questions: Does anyone have personal experience of medical practice in other states? If so, can you comment on whether you observed regional differences in how medicine is practiced?

—Charles R. Meyer, M.D.


Susan Jenkins, MD 10/16/2009 3:01 PM I'm a private practice, child and adolescent psychiatrist. I don't make money off any referrals or labs that I order. It's hard for me, in one of the most poorly reimbursed and most severely short specialties to feel like the rising cost of health care is in my lap. It would help if we could get reimbursed for time & expenses spent gathering and reviewing outside records since this would avoid repeat lab and imaging tests and also avoid repeating useless therapy trials. Where could we save a lot of money? A single payer system would eliminate a ton of overhead expenses overnight. Having clear guidelines to follow and being protected from malpractice if one follows them would also help. Also, having CPT codes reimburse for innovative practice that allows for efficiencies. Submitted By: Susan Jenkins, MD eholten@yahoo.com 10/15/2009 5:13 PM Are you surprised? Submitted By: eholten@yahoo.com Dr. Robert W. Geist 10/12/2009 8:58 AM Politically created gatekeeper corporations have failed to control costs or deliver quality. The "industry" and political response has been vilification of “poor quality” medical care specioulsy attributed to avaricious doctors being paid fees for services instead of for nebulous “healthy outcomes”. The "cure" is to transfer the "payer" gatekeeper function to capitated clinicians at the bedside: ration care...or go broke. The pitfalls are that this "cost cure" won't work--it failed in the 1990s. Political forces favoring subsidized “free” (low co-pay) care drive demand inflation, while socioeconomic poverty and low cultural status factors drive quality population statistics. These are forces and factors that have proved more powerful than state and corporate rationing of supply, and are forces and factors over which clinicians have no control from the bedside. Clinicians can treat the ailments of patients, but not the ailments of a system gone awry and battered by futile efforts to con dan reynolds, md 10/9/2009 2:08 PM I am a surgeon and part of a medium sized medical group. I have been in practice for 8 years and was previously part of a much larger medical group that is part of an HMO. In my review of the procedures that I perform I have seen a ten percent to twenty percent reduction in my reimbursements over the past 8 years and meanwhile the cost of delivering care has increased by more than 100% over that same time period. clearly there is more at work here than simply my activity or payments. Certainly physician behavior is directed by reimbursements, such as in the case of saphenous vein ablation. In that instance the surgeons fee is about the same as it is for an AAA repair. This has led to many resources being directed into creation of vein centers and pressure being placed upon vascular surgeons to perform more of these procedures for an essentially benign disease. And, there are many examples of this type of behavior. Also, the concern over litigation leads many to order tests that Robert E. Doan, M.D. 10/9/2009 12:28 PM Those reflections on reform are interesting. I did click on the Relman article and the Darthmouth article, and I certainly know there are regional differences. I tried to add my comments, but something about that reply system baffled me. There is a lot of testing that does not benefit the requesting physician financially. One good example: ER doctors see patients they have never seen before and perhaps feel they have their necks out a little further from a malpractice viewpoint. Result is more testing. Dr. Relman's proposal is HUGE! I practiced in a small internal medicine group most of my career, and I now work part time in nursing homes for a very large multispecialty clinic. There are advantages in both systems, and the big outfit is not always more economical. If the US Government is to prescribe how physicians are going to organize themselves, what expertise do they have to do the prescribing? I am sure you are swamped with ideas, and I have tried to keep my legislators John E. Downs 10/2/2009 9:36 AM Am I a part of the health care crisis? I am a medical testing nihilist. The question that must be asked before ordering any diagnostic test is, "How will the results of this test change how I manage this patient?" Rarely can I justify testing on a it would be nice to know basis. I also feel that if physicians had better neuromusculoskelal exam skills that many imaging tests could be avoided Submitted By: John E. Downs
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