Doctors in the trenches speak out – Part two

Here’s a second installment from the documentary Money-Driven Medicine. The producer, Alex Gibney, is an Oscar-winning filmmaker (Enron: The Smartest Guys in the Room). See the previous post for the first installment.

Bill Moyers: “Money-Driven Medicine is one of the strongest documentaries I have seen in years and could not be more timely. The more people who see and talk about it, the more likely we are to get serious and true health care reform.”

Maggie Mahar, author of the book on which the film is based, writes a regular blog called Health Beat. (emphasis added in the following excerpts from the transcript)

Specialists vs. Primary Care Physicians

Dr. Donald Berwick: If you look at the way we pay for care in the country and say, “Well, what is the underlying theme here?” We pay for doing things. A piece of surgery, performing a test, doing a procedure. Even a visit is a thing. So specialties or medical practices that do a lot of things, a lot of tests, a lot of surgeries, a lot of procedures; They’ll tend to be the higher income earning specialties.

Medical students leave medical school today with enormous debts. Primary care specialties are the lowest paying. If you have a choice between taking 15 years to pay off your debt or seven, you might decide on seven, and that means you can’t be a primary care doctor.

Maggie Mahar: What’s interesting about the fee schedule is that it’s all about what it costs the doctor to produce the service in terms of time and education. >Never does anyone ask, “How much benefit is there for the patient?” This might be a service that, on average, lengthens the patient’s life by 5 months, as opposed to having your diabetes controlled for 30 years, which means that you live a lot longer and you never have an amputation. And yet we would pay much more for that technically very skilled procedure that gave you another couple of months, because we look at it entirely in terms of the work on the part of the doctor rather than the benefit to the patient.

So we don’t value primary care doctors, generalists, family doctors highly at all. The compensation is relatively low and that’s why we have fewer and fewer of them.

Dr. Dan Larson: If the dollars to dollars ratio were even vaguely similar to specialty and primary care, I’d choose it again every time. I like the variety. I like doing different things. I wouldn’t like doing the same thing all day long. And I’m willing to take an income hit to be primary care, but it’s affected the quality of primary… the ability to deliver quality primary care in this country, because not enough people are going into it and, [that] makes it harder to put together an integrated system. And everyone pretty much acknowledges that if someone doesn’t have a primary care doctor they go to multiple specialists, there is more duplication of services at higher total health care cost.

Dr. Espinoza: You can’t just fix things in medicine. Medicine is a process. It’s a duration of treatments that occurs over the course of somebody’s lifetime. Yeah, there are things that we do that are very systematic and very matter of fact, so to speak, where you fix and “boom” they’re are on their way, but it’s just not a good way to develop a relationship. You need a rapport, you need trust, you need that patient, you know, having the ability to say, you know, “Yeah, Dr. Espinoza, that’s my doctor.”

The thing I miss most is being able to sit in a room and talk to a patient for an hour. But … we’re so compressed with our time and the amount of patients we have to see, … 15 minutes is a long time these days. … Basically … you get on the assembly line.

Does the hospital like you doing lots of procedures? Sure, … these procedures are reimbursed, fairly substantially. … [E]ven within your own group there is a component of productivity. … You wish things would just be about taking care of patients and doing the right things but … are there external pressures? Absolutely. Absolutely.

At the end of the day, if you just remember the fundamental principle that you have to have done something for that patient in order to make them feel better, live longer, … engage in a lifestyle that they weren’t able to engage in before, and if you stick to those principles, it allows you not to, kind of, drift from what you know is right and fall in to this arena where … you’re just slamming a stint in every blockage that you see. Because if you did that, then clearly it becomes… I would hate to use the term immoral, but it becomes an issue where you are doing things just to do them, not because it’s the right thing to do.

Waste

Maggie Mahar: What’s truly staggering is how much waste there is in our health care system. Up to one out of every three of the more than two trillion dollars that we spend is wasted on ineffective, often unproven procedures, overpriced drugs and devices that are no better than the drugs and devices that they’re replacing. Unnecessary hospitalizations, unnecessary tests. Now this may seem like an overstatement. I mean, how can it be that 1/3 of the money is wasted? We actually have close to three decades of research done by doctors at Dartmouth University proving how much waste there is in the system. … [W]hat they discovered is that in some high treatment states, like New Jersey, Medicare was spending 20 percent more per patient than the average. And in other low treatment states, like Iowa, Medicare was spending 25 percent less than average.

And here’s the stunner: The outcomes are no better. Often they are worse on average in states like New Jersey or New York or California than they are in low treating states like Iowa or North Dakota.

Related posts:
Doctors in the trenches speak out – Part One
Doctors in the trenches speak out – Part three
Why are US health care costs so high?
Health care reform: Navigating the maze
Health Culture Daily Dose #6: Health care reform
Health Culture Daily Dose #11: Health care reform
Edward Kennedy: Healthcare is a fundamental right, not a privilege