Paying Doctors

There’s been a lot of talk lately about changing how physicians are paid as a part of health care reform. Many have recommended that pay for primary care physicians be increased, arguing that this will increase the number of doctors practicing primary care, leading to higher quality care along with lower costs. As a primary care physician I totally agree with this. There have also been bad ideas raised, such as returning to capitation despite how badly this idea has failed in the past. Today The New York Times has a round table on physician reimbursement.

Elliott S. Fisher, a professor of medicine and director of the Center for Health Policy Research at Dartmouth Medical School, recommends:

One approach that has shown some early promise is to combine the fee-for-service with “quality bonuses” and “shared savings” payments when they reduce spending growth for all of their patients. Doctors, hospitals and society should realize that slowing spending growth would not require dramatic cuts in income under a system where providers would be rewarded for better care, not just more care.

In general that is what some are now trying, but so far such ideas have been poorly implemented. One major problem is that it is hard to measure quality and tell what is really going on in all the offices around the country. At present incentive payments are so low that it often isn’t worth the administrative expenses to submit the data to qualify. General measures of quality often do not apply in specific cases. While practice guidelines are often written for a specific disease, in the real world patients have multiple problems and sometimes the recommended care for any specific condition is not the appropriate care for the individual patient.

Sometimes insurance companies will try to analyze whether a patient is receiving all the appropriate medications based upon diagnoses submitted. The entire concept is flawed as often diagnosis codes are used for suspected ailments to justify testing, and sometimes one person seeing a patient enters a diagnosis into the system which is simply incorrect. Even if they have the correct diagnosis, particular medications might be not be tolerated by certain patients, or a patient might simply refuse to take them. Sometimes the actions of doctors to help patients turns out to be counterproductive with regards to quality measurements. We might give a patient samples, or switch the patient to a generic medication they can receive for less than their insurance co-pay at certain pharmacies. To the insurance company it appears that the patient is not receiving a needed medication.

Steffie Woolhandler and David Himmelstein, associate professors of medicine at Harvard Medical, note that every system has its flaws:

There are a variety of bad ways of paying doctors, but no particularly good ones. Fee-for-service health care rewards the overprovision of care; capitation (a set monthly fee per patient) rewards underprovision; and salaries reward just showing up. The minority of physicians (and hospital administrators) who are motivated mostly by money will find a way to game an incentive system rather than do the hard work of providing excellent care.

Even paying doctors based on quality measures (using data from medical records that the doctors themselves create) can be fudged.

They support a single payer system, noting the tremendous cost savings on administrative expenses, but that still leaves the question of how to pay doctors unanswered.

Liam Yore, an emergency room physician, points out a serious problem with the current system:

The underlying cause, however, is a bias within the physician compensation system that extravagantly rewards surgical procedures performed compared to “cognitive” services like diagnosis and medical management. In the E.R., for example, sewing a facial laceration pays far better than accurately diagnosing a heart attack. The same principle applies to any procedure — from angiograms to colonoscopies.

The predictable consequence is that physicians gravitate toward lucrative procedural specialties. They perform more and more procedures, using expensive new technologies, driving costs ever higher.

Meanwhile, office-based primary care doctors struggle. The compensation for an office visit is a tiny fraction of that for the simplest procedures. The family physician must rush from patient to patient just to keep pace with static or diminishing reimbursement. Fewer and fewer medical students are going into primary care.

What we need to do is rebalance physician compensation away from procedures and toward primary care. Surgeons can easily earn three to five times the average salary of a family doctor. The compensation for surgical procedures should be reduced, and the savings realized should be applied toward increasing pay for primary care physicians.

Better-compensated primary care specialties would attract more doctors who would be able to spend more time with their patients. They would require fewer expensive diagnostic tests like M.R.I.’s and rely less on specialists. Accordingly, the use of expensive and invasive procedures would decline. Prevention, wellness and chronic disease management would be encouraged: enhancing quality and patient satisfaction, but at a far lower cost.

Primary care is the linchpin to successful health care reform. Ignore it, and reform will fail. Make it an appealing career choice, and the odds of success increase greatly.

Excellent Damage Control

jenny sanford

We often see cases of poorly handled damage control which makes the situation worse. Mark Sanford provides just the latest example. On the other hand, his wife Jenny Sanford is doing an excellent job of enhancing her own reputation despite all the publicity. Perhaps that’s why some say she was “the real brains behind the operation.”

Whenever I’ve seen a television news report on her she has been quoted talking about caring for her children. Presumably this is sincere, but regardless it is the perfect answer under the circumstances. Otherwise she avoids getting into the dirt. She did manage to get out one piece of information which protects her from any potential criticism that she should be standing behind her man:

Through a spokeswoman, Mrs. Sanford declined requests to be interviewed for this article, but told The Associated Press she learned of her husband’s affair early this year when she found a letter he had written. She told him to end the relationship, but he repeatedly asked permission to visit the woman in Argentina in the months that followed.

“I said absolutely not,” Mrs. Sanford told The A.P. “It’s one thing to forgive adultery. It’s another to condone it.”

Then, last week, when the governor told her he needed time alone to write, she had specifically warned him not to see his mistress. She said she was devastated when he went to meet her in Argentina.

A Dangerous Idea

It might just be a trial balloon, or perhaps unsubstantiated rumor, but Obama needs to reconsider the idea of issuing an executive order regarding preventive detention.

I realize that he was left a mess by Bush. Now that the people have been held without due process it is hard to try them at this point and there are some who should not be released. Still we cannot risk setting a precedent which seems to legitimize the actions of George Bush.

Not Everyone Can Be A Comedian

I really like John Kerry and think he would have made an excellent president, but he really needs to stop trying to tell jokes.

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God and Science

Lawrence Krauss has an op-ed in The Wall Street Journal explaining why God and Science Don’t Mix. The article came from his participation in a panel discussion at the World Science Festival in New York City on Science, Faith and Religion. Krauss argues that “A scientist can be a believer. But professionally, at least, he can’t act like one.”

There are difficulties  in questioning whether science and religion are compatible. There are many scientists who are also religious, while there are also many religious conservatives who see science as a threat. Krauss wrote:

These scientists have been castigated by believers for claiming that science is incompatible with a belief in God. On the one hand, this is a claim that appears manifestly false — witness the two Catholic scientists on my panel. And on the other hand, the argument that science suggests God is a delusion only bolsters the view of the of the fundamentalist religious right that science is an atheist enemy that must either be vanquished or assimilated into religion.

Coincidentally, I have appeared numerous times alongside Ken Miller to defend evolutionary biology from the efforts of those on various state school boards who view evolution as the poster child for “science as the enemy.” These fundamentalists are unwilling to risk the possibility that science might undermine their faith, and so they work to shield children from this knowledge at all costs. To these audiences I have argued that one does not have to be an atheist to accept evolutionary biology as a reality. And I have pointed to my friend Ken as an example.

The views of fundamentalists are inconsistent with science and what we know of the real world as they reject scientific findings which conflict with religious teachings.  Religious fundamentalists develop a wide variety of arguments to contradict scientific findings where science conflicts with their views on subjects such as evolution and the age of the earth. Some will argue that any evidence that the earth is older than 6000 years was planted by God to test our faith. The Discovery Institute has published numerous claims to oppose evolution which fail to hold up to scrutiny.

Science, in contrast, is constantly tested and theories must be abandoned if they are found to be inconsistent with the evidence. P.Z. Myers describes the difference between obtaining knowledge of the universe with the scientific method versus explaining the universe based upon religious dogma:

We have to look at what they do to see why. In order to probe the nature of the universe around us, science is a process, a body of tools, that has a long history of success in giving us robust, consistent answers. We use observation, experiment, critical analysis, and repeated reevaluation and confirmation of events in the natural world. It works. We use frequent internal cross-checking of results to get an answer, and we never entirely trust our answers, so we keep pushing harder at them. We also evaluate our success by whether the end results work: it’s how we end up with lasers and microwave ovens, and antibiotics and cancer therapies.

Religion, on the other hand, uses a different body of techniques to explain the nature of the universe. It uses tradition and dogma and authority and revelation, and a detailed legalistic analysis of source texts, to dictate what the nature of reality should be. It’s always wrong, from an empirical perspective, although I do have to credit theologians with some of the most amazingly intricate logical exercises as they try to justify their conclusions. The end result of all of this kind of clever wankery, though, is that some people say the world is 6000 years old, that it was inundated with a global flood 4000 years ago, and other people say something completely different, and there is no way within the body of theology to resolve which answers are right. They have to step outside their narrow domain to get an independent confirmation — that is, they rely on science to give them the answers to the Big Questions in which they purport to have expertise.

Krauss quotes J.B.S. Haldane, an evolutionary biologist and a founder of population genetics, on the those who “extrapolate the atheism of science to a more general atheism.”

My practice as a scientist is atheistic. That is to say, when I set up an experiment I assume that no god, angel or devil is going to interfere with its course; and this assumption has been justified by such success as I have achieved in my professional career. I should therefore be intellectually dishonest if I were not also atheistic in the affairs of the world.

It is not necessary for scientists to totally reject religion but scientists must be willing to abandon religious dogma when it conflicts with information established with the scientific method.  Krauss  found that, at least among those in this panel discussion, religious scientists were certainly not fundamentalists and were willing to accept views on religion which do not take religious teachings literally:

When I confronted my two Catholic colleagues on the panel with the apparent miracle of the virgin birth and asked how they could reconcile this with basic biology, I was ultimately told that perhaps this biblical claim merely meant to emphasize what an important event the birth was. Neither came to the explicit defense of what is undeniably one of the central tenets of Catholic theology.

Krauss concludes with noting that this conflict between science and religion is relevant to real world issues:

Finally, it is worth pointing out that these issues are not purely academic. The current crisis in Iran has laid bare the striking inconsistency between a world built on reason and a world built on religious dogma.

These issues can also be seen far closer to home than in Iran. The differences between the modern conservative movement and liberals, moderates, and the few remaining rational conservatives also come down to whether one has a view of the universe based upon religious dogma or based upon science and reason. Fortunately, while countries such as Iran are dominated by religious fundamentalists, since the Republican Party became dominated by fundamentalists it is quickly turning into a minor regional party of the deep south and Mormon belt of the west. As the Founding Fathers realized when they established a secular government with separation of church and state, religion and politics do not mix any better than religion and science.