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Saturday, October 10, 2015

It's the payment system, stupid

It have taken a long hiatus from writing. I am not sure why. Part of the reason may be I have been so busy with work. Part of the reason has also been the world is so confusing that I did not believe I could say anything useful or coherent. Finally, writing required that I sit in front of a computer for even more time. My Fitbit has prompted me to get up and move. When I move, I don't write. Perhaps I need to buy a walking computer desk. Sounds dangerous...

I had a conversation with one of my colleagues at work this week which got me to thinking. He was a former ENT physicians who rose to leadership positions. He remarked that when he ran his department, there were always patients with particular diseases whom no one wanted to care for. For ENT these were the dizzy patients. No one wanted to see the dizzy patients. There was no shortage of calls for help. There are lots of dizzy people who are simply miserable with their disorder (the 12 month prevalence may be as high as 5%), but a limited to non-existent workforce who want to treat these afflicted individuals.

This is not specific to ENT and dizzy patients. For dermatologists, there are the itchy patients; for the rheumatologists the fibromylagia patients; for the gastroenterologists it is the irritable bowel syndrome patients; for the neurologists it is patients with headaches; for the hemologists/oncologists it is anyone who does not have cancer; for the orthopedists it is patients who have back pain who are not operative candidates. There are common and awful conditions which may be terribly debilitating. Yet it is common knowledge that the care community view these entities as one might view the old maid card in the card game. One is best served by passing this off to someone else.

What all of these things have in common is that they are common entities, rarely life threatening, may be difficult to treat, and most importantly, their value in the medical payment lottery has been arbitrarily set below where it provides incentives for health care professionals offer care to patient afflicted. The payment system has created huge disincentives for physicians and health systems to offer services to patients with these common and debilitating (but non-lethal) conditions.

In virtually all other sphere of human endeavors, unmet human needs and wants create opportunities for people and businesses to grow wealthy by stepping to meet human needs. This is not so much true within health care. The convergence of top down administrative pricing schemes and restrictive and punitive participation rules has created a sorry state which has basically orphaned huge segments of care needs. Let's say I am a neurologist who might have an interest in the care of patients with chronic headaches. The estimates are that this symptom affects about 50% of the population in any given year and 3% have chronic disease (meaning > 15 days per month - about 10 million people!).  If I follow evidence based guidelines, I will find managing these patients a financially losing proposition because the payment system (E&M codes primarily) arbitrarily assigns payments below the level of cost of delivery of service. As a rational person, I leave this business.

In other businesses, the shortage of supply allows remaining players to adjust the price of service to the point where continued delivery of services can be maintained or grown to meet needed demand. In health care, prices are fixed and almost impossible to respond to unmet demand. Yes, one could consider pulling out from Medicare or private contracts but it is much lower risk to simply offer other services which pay much better.

For the patients who have headaches, non-specific GI discomfort, itching, dizziness, fibromylagia, or similar states who get through the filters into your office, they will not likely come back if the level of service is sufficiently dismal. Whether intentional of not, there are benefits from the deployment of strategic clinical incompetence. Thus, there has been a wholesale exodus from providing care to patients with a host of very troubling, uncomfortable, debilitating and remarkably common conditions. No wonder the alternative medicine industry has moved in to fill this void.

Leadership within the conventional health care ranks are blind to much of this. To keep your health care delivery teams happy and financially healthy, it is essential to keep these patients out of your system as much as possible. One is best served not to give much thought to the origins of this issue.

Look at virtually any medical office or system's website and you will see various offerings of what that group is marketing to the public.  I reviewed the Mayo clinic site and typed in a series of symptoms or conditions. When I typed in chest pain, joint replacement,  or cancer, I got an informational site which had a "request appointment" button. When I typed in headache, itching, or dizziness, I got information but no opportunity to request an appointment. How interesting....

However, the movement toward consumer driven care may unmask this problem. I think it is only a matter of time before the public becomes aware of the disconnect between what we are incentivized to do and want to do currently and what unmet needs exist. My concern is that the response will be heavy handed, top down, and will double down on the current dysfunctional payment system. It will create just a new set of winners and losers based upon political games.