Doctors who manage patients in the office aren’t the problem

I am riled up—almost to the point of being inflamed.

I hate it when doctors get dragged through the mud. It’s a matter of pride. Doctors are my team.

The latest kerfuffle centers on how much we should charge for return patient visits. The difference here is between moderate and moderately high visits–or about $30.

When the Center for Public Integrity is investigating your profession, it’s unlikely to be good news. And it wasn’t. This time however, the usual baddies (back surgeons, cardiologists and other high-paid specialties) were not the culprits. Rather it was the worker bees of Medicine—office-based doctors.

In an exhaustive review of Medicare billing databases over the past decade, CPI found that doctors have gradually billed at a higher complexity for return patients. The Cracking the Codes investigation is exhaustive but can be boiled down to just this: a flip-flopping of Level 3 (of 5) codes for Level 4. The lowest codes and highest code did not change much. Again, the delta here is about $30.

There’s a lot been said on this matter already. My take is that it should serve to remind us of the big picture of what’s wrong with US healthcare.

Start with the givens:

US healthcare costs too much.
We consume too much of it.
We overemphasize medicines, tests, procedures and surgery.
We undervalue cognitive tasks.

It’s well known that the US healthcare model favors doing. Procedure-related specialties like mine are compensated much more favorably than non-interventional fields. My thumb injury this summer illustrates this point: After having hand-surgery, I sat out of procedures for 6 weeks. This didn’t mean I missed work; I still came into the office and saw patients. As wonks say, I evaluated and managed patients. As I found out when looking at my productivity-based paystub recently, E&M work pays less than procedures—substantially less. And it was much harder work seeing patients all day. I know, this is not news.

Neither is this idea. That one way to reduce over-consumption of expensive health care is to emphasize office-based doctoring. The dreamy notion holds that doctors could take the time to learn about their patients, educate about healthy lifestyles, thoroughly explain treatment alternatives—including less-expensive stuff like giving a disease a tincture of time to abate naturally. Atrial fibrillation is a good example. I can (almost) do an AF ablation in the same time it takes to really explain all aspects of AF care to a new patient. One hour in the office with an AF patient pays about ten-fold less than that amount of time in the EP lab burning the atria. Truthfully, sometimes I question which hour is more valuable.

My wife’s work as a hospice and palliative care doctor offers another example of misplaced incentives. The human suffering relieved by hospice doctors is staggering. We will all die, and those not blessed to pass peacefully benefit immensely from skilled and compassionate end-of-life care. But again, in the time it takes my wife to see a new patient, address their goals of care, implement a treatment plan and give counsel to a grieving family I could implant two ICDs—and make more than ten-fold more.

It’s not right.

If we do one thing to change our healthcare system for the better, it would be to truly and wholly incentivize cognitive, non-procedure-based doctoring. We need the smartest doctors on the front lines of healthcare. We need them wanting to be in the office helping people to not need so much care.

That’s why I hate that the implications of “Cracking the Codes.” It suggests malfeasance on the part of doctors who do E&M work. Nothing could be further from the truth. As a lot, these are hard-working people doing important work. And even if you posited an over coding of level 4 visits, the impact is peanuts compared to the widespread over-use of really expensive care. Doubters can follow me for a tour of an ICU or emergency room—or even a cath lab.

Doctors who evaluate and manage patients in the office aren’t the problem. The problem is that we don’t have enough of them—because we don’t value their work. My friend and colleague, Dr Wes Fisher suggests that we compensate by time spent rather than boxes checked. That’s a good start.

Another would be to do the obvious.