As I mentioned earlier, I’m starting to rev up the studying for the licensing exam. A lot of the studying takes the form of practice questions. They’re actually a lot of fun to do: they force you to think actively about the clinical scenario, keep you on your toes, and make it near-impossible for your eyes to glaze over as you semi-consciously read the same page for the 10th time in a row as your eyelids begin to feel heavy, droop, and you start to….
Yikes! Where was I? Right! The Cavalcade is back! Since I’m sure that most of you don’t believe me when I say that doing practice questions is actually fun, I’m going to use this opportunity to try to convince you. With the aid of sophisticated, peer-reviewed psychometric techniques (or not), I have converted each entry into a USMLE-style “single best answer” multiple choice question. Let’s see how you do!
Cavalcade of Risk: Step 1
Instructions: For each of the following test items, select the one answer that best answers the question posed in the stem.
From Boomer at Boomer&Echo: Which of the following behaviours of financial advisors correlates with the lowest risk of defrauding investors?
a) Claiming to have secret/exclusive insider tips that “your broker doesn’t want you to know.”
b) Counseling clients that investments with higher expected returns tend to be riskier.
c) Offering to move your money offshore to avoid taxation.
d) Pressuring you into making a hasty decision on an “exploding offer.”
e) Charging abnormally high membership fees.
From Ken Faulkenberry at the AAAMP Blog: If shares of the Notwithstanding Blog Internet Empire (NBIE) earned a 8% return in 2011 and exhibited a beta of +1.2 relative to a benchmark of shares in all medical blogs that collectively earned a 5% return, then:
a) The alpha for NBIE in 2011 was +2, making it a good investment.
b) The alpha for NBIE in 2011 was +3, making it a good investment.
c) The alpha for NBIE in 2011 was -3, making it a bad investment.
d) The alpha for NBIE in 2011 was -6.8, making it a bad investment.
e) The alpha for NBIE in 2011 cannot be calculated with this information.
From Van R. Mayhall III at the Insurance Regulatory Law Blog: Which of the following statements DOES NOT accurately characterize insurance company insolvency:
a) Most state-based insurance guaranty associations are more comparable to private member-based associations than true state agencies.
b) Insurance companies are subject to unique state-based insolvency protocols in lieu of entering the federal bankruptcy system.
c) Payouts from state insurance guaranty associations are subject to statutory caps.
d) Insurance guaranty associations are intended to provide “bailout” financing to prop up faltering insurers.
e) None of the above.
From Emily Holbrook at Risk Management Monitor: The shoe-shopping website Zappos.com recently earned positive press for:
a) Losing your examiner’s personal information, along with that of millions of other customers.
b) Locking out customers from your examiner’s home country for 4 days after a data breach.
c) Being named in a potentially-class action lawsuit seeking damages as a result of a data breach.
d) Having “some analysts” criticize the company’s response.
e) Having “some analysts” praise the company’s response.
From Jason Shafrin, the Healthcare Economist: Medicare’s new value-based purchasing initiative, which aims to reduce payment to “low-quality” doctors, currently uses treatment costs for which of the following chronic diseases as an element of its cost measure (as distinct from its quality measure):
b) Alzheimer’s disease
d) Lung cancer
e) Breast cancer
From Louise Norris at Colorado Health Insurance Insider: Colorado’s Medicaid program has recently undergone much change and provoked a great deal of controversy. What happened at the end of 2010 to put Colorado’s Medicaid program on better financial footing?
a) Successful negotiations to lower the fee schedule for physicians’ services.
b) A 55% increase in enrollment relative to 2007.
c) A one-time $13.7 million grant from CMS.
d) New dedicated revenue from a sales tax increase.
e) The introduction of Medicaid Managed Care programs.
From Dr. Jaan Sidorov, the Disease Management Care Blog: Which of the following is an accurate characterization of Dr. Sidorov’s assessment of Health Insurance Exchanges (HIEs) and recent Kaiser Health News commentary on the subject?
a) The left is doing their best to nurture this fledgling institution to maturity in anticipation of the PPACA’s full rollout.
b) It’s reasonable for consumers to spend more time shopping for consumer electronics than for health insurance.
c) Government-run HIEs will eventually match the ease-of-use and “cool” factor of iPhone apps and online purchasing aids.
d) Multiple insurance options on HIEs include variations in provider tiers, out-of-pocket costs, and exclusions.
e) Consumer expectations for HIEs will eventually be exceeded.
From Julie Ferguson at Workers Comp Insider: Doctors’ deaths differ from the deaths of other Americans in that:
a) Doctors often choose to forgo lifesaving chemo, radiation, and procedures.
b) Paradoxically, doctors often do not have access to the full range of lifesaving technologies as the rest of society.
c) Non-physicians tend to be more ready to accept death.
d) Doctors have a cultural bias against accepting death that isn’t shared by society at large.
e) Non-physicians who choose to fight their disease are often pressured by friends and family to be serene in the face of death.
Of course, since you read all the entries, you don’t need one! But just in case: B; A; D; E; C; C; D; A.
As always, it’s an honour and a pleasure to host the Cavalcade of Risk! If this is your first time at the Notwithstanding Blog, or if you’re coming back after a prolonged absence, I encourage you to take a moment and poke around some of other posts here. From health care policy to health professions training (i.e. medical school), I’ve got it covered.
The 150th(!) Cavalcade will be hosted on February 8th at My Wealth Builder.
There was a post at KevinMD.com not a few days ago that was as interesting for its comments as it was its content. In the post “Consumer-Driven Healthcare Will Only Shift Costs if Implemented Poorly,” the author argued that “consumer-driven” insurance requires consumers to have access to at least a minimum degree of information to guide their decision-making. If employers/insurers shift both the costs and decision-making about healthcare onto their employees/insured, the latter will require either structural “nudges” or other decision-making support to be able to access the care they need and save money.
A brief discussion in the comments brought out what is one of the more common objections I hear to any attempt to move health insurance in the direction of high-deductible catastrophic care policies: “how are patients supposed to find information on quality and price from physicians and hospitals? It’s not there? This can’t possibly work!”
It’s not a trivial objection, but when all is considered I can’t say that I’m convinced by it.
It’s not as though the health care industry hasn’t caught onto the need to devise, assign, and disseminate cost values for different tests and procedures (even if only for internal purposes), even where cost was never previously a consideration. See the recent highly-publicized study in Archives of Surgery finding that merely giving medical staff information on blood test costs reduced spending by lowering utilization.
As more and more patients start asking for real price and quality data, providers will have an incentive to find it and give it to them. With traditional third-party payment, what does it matter to the physician? They get paid what someone else says they get paid. If my classmates are representative of future physicians more generally, most would far rather not even have to think about pricing and bundling their own services if they don’t have to. That won’t change unless there’s a demand for it, and right now the main source of that is patients with consumer-directed plans.
We already have a great deal of beneficial, effective competition on both price and quality in areas of the health care market that are actually markets, and in which people tend to pay out of pocket. Think of the trends of both price and quality of laser eye correction over the last few decades, or cosmetic surgeries that aren’t covered by insurance. These are elective procedures with real risk of misadventure, as with many services provided by physicians and hospitals. The reason that price and quality data are easier to come by for LASIK than for cardiac catheterization is precisely because patients have an interest in knowing. This isn’t to say that the process of developing the data is necessarily quick and easy, but surely this should disprove claims that transparent pricing “could never happen” in health care more generally.
Right now, I’d imagine that the people most likely to sign up for consumer-directed health plans (though obviously there are many exceptions) are those who want to, or at least are comfortable with managing more of their health care spending in exchange for lower premiums and capped out-of-pocket spending. As with any other new product, it is the early adopters who will pave the way forward for other consumers. My prediction is that as a small but growing group of patients and physicians begin to leave the third-party payment model, whether via HSAs or by exiting insurance entirely for some services, the medical industry will get better at providing transparent price and quality information to everyone who asks. CDHPs (and the providers who accept them) today may be like the first cell phones in the 1980s: as the early adopters push for improvements, we’ll see the product evolve into something that can be used more widely in the future.
Yes, there is something of a chicken-and-egg problem right now. But it’s anything but intractable, and certainly won’t be a problem forever.
There is a strong argument to be made that transparency and competition on quality goes hand in hand with price competition. John Goodman from the NCPA makes the case here and here, among other places.
I’m surprised that it’s taken me so long to devote even a cursory post to health care in Canada (or as it’s referred to back home, “medicare”). After all, as my disclaimers page says, “if the blog title didn’t give it away, I’m Canadian.” However, a recent series of posts at Medscape’s medical student blog “The Differential” [free registration required] inspired me to take on the subject.
I want to make clear at the outset that this post is intended to be descriptive. My thoughts on Canadian medicare and its implications for proponents of single-payer in the US can wait for another time.
Before delving into the Medscape commentary itself, we should begin with some general background on health care in Canada.
 – Much of this background was assembled while preparing a presentation that for the first health economics course I took in university. I have done my best to bring things up to date. Depending on the minutiae of when laws are introduced vs. passed (and which of the two you refer to), some of the earlier dates in the History section may be 1-2 years off from what you read in some other sources.
Canadians feel strongly about their medicare. Most of them love it, or at least love the idea of it. If you’re a politician wanting to discuss the system in terms of anything other than providing more funding for the system, you’re likely to be toast in short order. And don’t even think about promoting “two-tier” health care! Governments at the federal and provincial level have risen and fallen based on the health care issue; it’s a major component of provincial government spending, and many Canadians view medicare as a component of national identity.
Government involvement in Canadian health care began in earnest in 1944, when the government in the province of Saskatchewan introduced a system to provide free health care to the elderly and retirees. This was followed shortly in 1947 by a public hospital insurance plan featuring a $5/person/year premium. In 1959 the socialist government of Tommy Douglas (considered one of the “fathers of medicare“) announced the first universal public health insurance program in Canada. Needless to say, Saskatchewanian (Saskatchewanite? Saskatchewanish?) physicians were wildly opposed, even going on strike for a few weeks in 1962.
A decade later, the ideals that drove the new program in Saskatchewan came to fruition on the national stage, as medicare was introduced in the remaining Canadian provinces beginning in 1967. This was not done in one fell swoop. The constitution in Canada has established health care as the domain of the provinces. The federal government rolled out medicare across the country not by fiat, but by offering matching funds (now block grants) to provincial health plans that met certain legislative criteria; this has given the federal government an important role in both financing and “regulating” provincial health care plans, though in recent years the federal share of health financing has fallen as low as 15-20%, with the rest paid by the provinces. In this sense, the structure of Canadian health care financing more closely resembles that of US Medicaid than of US Medicare. It should also be noted that both the earlier and current iterations of provincial health plans covered mostly to exclusively hospital and physician services: no home care, drugs, devices, etc.
Federal Legal Framework
By the mid-1970s, the last Canadian province had signed on to medicare and the program was not due for another major shake-up until 1984, the year the Canada Health Act was passed. The CHA is still the current governing framework for public health care in Canada. It re-affirmed the five basic criteria and two conditions for federal funding, but unlike the previous federal legislation, the CHA more clearly authorized the federal government to withhold transfer payments as a penalty for provincial transgressions.
The CHA imposes 5 basic eligibility criteria for provincial plans to receive federal support.
- Public administration: each province’s health plan must be administered by a publicly-accountable, non-profit entity. In practice, this is usually a government agency or arm’s-length government-owned insurer.
- Comprehensiveness: all “medically necessary” services must be covered, though provinces get surprisingly wide latitude in defining what is medically necessary.
- Universality: all residents of a province must have access to public insurance on the same terms and conditions. In other words, all insured must be equal, and all are equally insured. The Act defines “insured persons” in such a way that treatment sought under worker’s compensation or auto insurance regimes escapes some of the dictates of the Act. In addition, provinces are allowed to impose minimum residency length requirements (e.g. 6 months in Ontario) before residents are eligible for coverage; in some provinces, this even applies to Canadians moving from other provinces.
- Portability: provincial plans must reimburse insured persons for medical services used during temporary absences from the province, at least at the rate specified in the provincial plan’s fee schedule.
- Accessibility: access to coverage must be uniform and barrier-free. There can be no discrimination or disparate treatment based on age, income, health, etc. On the provider side, provinces are required to have a clear and transparent fee schedule, with providers being “reasonably” compensated.
In addition, the CHA imposes two more specific conditions on funding that cut more closely towards health care delivery, as opposed to the five conditions that govern financing.
- Balance-billing (or “extra-billing” as it’s sometimes called in Canada) is banned. Physicians and hospitals are not allowed to charge provincially-insured persons for provincially-covered services in addition to the province’s payment for the service. This is similar to US Medicare’s ban on balance-billing.
- Provinces are not allowed to impose “user charges” for insured services. This became an issue recently as the government of Quebec toyed with the idea of introducing modest co-pays for some services for some insured. Not allowed.
The result is a “system” that’s not just one system. Each province (and possibly each territory?) has its own provincial health insurance plan that is run subject to the constraints of the Canada Health Act. The federal government administers health plans for members of the armed forces, the RCMP, and First Nations living on reservations. Worker’s compensation and auto liability insurance also play small roles.
The provincial plans are the major players, and are what most people in Canada and the US think of when they discuss the “Canadian health care system.” Though the criteria laid down by the CHA result in the appearance of national uniformity (and to be fair, a good deal of actual uniformity) in how health care is financed, administered, and delivered in Canada, there is a good deal of meaningful variation between provinces.
The Private Sector
One important dimension of variation is the role of the private sector in delivering and insuring services that are covered by provincial plans. As of 2005 (I haven’t looked more recently, but am unaware of major changes since them):
- Four provinces (QC, AB, BC, PEI) allowed physicians and other covered providers to set their own fees for providing covered services without billing the province. However, these provinces did not allow any reimbursement of patients or providers for covered services not billed to the province. In addition, these provinces banned private insurance coverage of any service covered under the provincial plan, even if delivered in the private setting. In 2005, a physician and his patient sued the Quebec government, arguing that the ban on private insurance coverage of privately-delivered publicly-covered medical services violated the Canadian Charter of Rights and Freedoms and the Quebec Charter of Rights and Freedoms, especially given long waiting times for treatment in the public system. The case made its way to the Supreme Court of Canada, which ruled that the prohibition violated the Quebec Charter of Rights and Freedoms. Given that the decision was grounded in QC provincial law, it had only limited direct impact in the other three provinces.
- Three provinces (ON, NS, MB) forced providers going outside the public payment system to charge at the public fee schedule. They also banned private insurance coverage of privately-delivered care that was also covered by the provincial plan, though two of these provinces (ON, MB) reimburse patients for out-of-pocket expenses paid to private providers.
- Three provinces (SK, NB, Nfld) allowed unfettered private delivery and private insurance for services covered by the provincial health plans. Newfoundland would reimburse patients for out-of-pocket expenditures to private providers up to the provincial fee schedule, whereas SK and NB provided no reimbursement for private expenditures.
- Private diagnostic clinics were beginning to emerge in three provinces (QC, ON, AB) in response to a pervasive lack of timely access to diagnostic imaging services. Though these clinics operated outside the public system, Ontario and Alberta actually contracted with some of them to provide services to public patients. For those with the means, however, payment could secure an earlier appointment for imaging, shortening the amount of time waiting for a diagnosis, and where applicable allowing earlier entry into a queue for treatment.
A National Single-Payer?
One of the features of health care in Canada that is often overlooked by proponents of single-payer in the United States is that Canada as a whole does not have a “single payer,” which means it’s hard to make sweeping generalizations about details. Covered services, the quality and quantity of care provided, and physician/provider payment vary across provinces. Not earth-shatteringly so, but enough to introduce a small modicum of inter-provincial competition for physicians, and “competition” in services and benefits mediated through political pressure (e.g. “Patients in BC can get this drug, why won’t you pay for it here in Nova Scotia!”). Given the perennial importance of medicare as a political issue, the importance of popular pressure to increase funding and expand services should not be trivialized.
It’s also worth pointing out that about 30% of Canadian health care spending is individuals’ out-of-pocket payments for things like drugs, home health, hospital amenities, and other non-covered services. This is 2-3 times the fraction of health care spending in the US that comes directly out of individuals’ pockets in exchange for services received.
Unions, Public Employees, and Hospitals
Contrary to what I’m told is common belief in the US, most Canadian physicians are not government employees. Though some provinces hire doctors for what I surmise are analogues to Community Health Centers, the vast majority of physicians are independent contractors paid on a fee-for-service basis according to the provincial fee schedule. In Ontario, some family physicians practicing in so-called “Family Health Teams” are capitated, and some emergency physicians are paid by the hour. An interesting wrinkle is that some provinces have hard caps on how much a physician can earn in any year; obviously this creates disincentives to working so hard / so much that the cap would be reached in a year. (It’s not just hypothetical: I have a few physician friends in Canada who have made great strides in their golf game as a result of this cap).
Hospitals, on the other hand, are closer to highly-regulated public utilities. In Ontario, most hospitals are non-government or arms-length, non-profit entities. Most of their money comes from a “global budget” (i.e. “this is your budget for the year”), though there have been experiments with US Medicare-like prospective payment systems for certain conditions. Patients also pay per-diem fees for non-covered amenities (e.g. private inpatient rooms, phone and TV service as inpatients). Provinces (or regional health authorities, or whichever provincially-created entity is in charge in a given province) have at least some control over hospitals’ capital spending. In Ontario, regional health authorities determine what sorts of specialty services and facilities are available at which hospitals within their purview. Hospitals are allowed to engage in public fundraising for capital campaigns; I’m not sure how this interacts with provincial controls on capital spending.
Physician licensing and governance is a point of special interest to me. There is the usual plethora of physician groups, specialty societies, etc., similar to what is found in the US. However, given the effective monopsony power of provincial governments in the market for physicians’ services, provincial medical associations have emerged whose main function is to represent physicians in fee schedule negotiations with government. Canadian physicians seem to have more input into provincial fee schedules than American physicians do into Medicare fee schedules. Whereas American physicians set the relative weights of various services in the Medicare fee schedule (and only indirectly lobbying for changes in the monetary conversion factor), Canadian physician organizations typically negotiate for dollars directly with government.
The Ontario Medical Association is one of these organizations. Unlike groups such as the American Medical Association, their orientation (and their website!) is very physician-centric. In addition to negotiating the terms of the provincial fee schedule, the OMA also sets maximum rates that physicians can charge for certain non-covered services (phone consultations, insurance forms, etc.).
Physician licensure and discipline is also done at arm’s-length from government. Unlike in the US, where medical licenses and disciplinary action are typically the domain of state government medical board, most (if not all) Canadian provinces have allowed the medical profession to remain somewhat self-regulating. For instance, the College of Physicians and Surgeons of Ontario is the licensing and disciplinary body for physicians in Ontario. Its governing body is composed of 16 physicians elected by their peers, 3 physicians selected from Ontario’s 6 medical school faculties, and 13-15 members appointed by government. Also of note is the fact that many provinces, including Ontario, condition licensure on the Canadian equivalent of specialty board certification. The opposite conditionality holds in the US.
By the Numbers
It would be foolish to try to replicate this series of three posts at the Healthcare Economist, where Jason Shafrin does a wonderful job of collecting the major summary statistics for infant mortality, life expectancy, access to care measures, and physicians per capita.
In an upcoming post, I’ll discuss common American medical student perceptions of Canadian health care (as exemplified by the post at The Differential mentioned at the outset, and with some telling anecdotes from March’s AMSA conference), along with the always-hot topic of waitlists for treatment.
Few physicians are fans of the Sustainable Growth Rate: the formula by which Medicare is (supposed) to make adjustments to physician payment each year. Primary care physicians would be especially hard hit by the massive payment cuts that the formula calls for. So far, these cuts have been staved off for months at a time over the course of the last few years, resulting in a cycle of impending doom followed by temporary relief as the can is kicked yet further down the road.
The Wall Street Journal’s Health Blog had this to say on physician organizations’ proposals to Congress for longer-term solutions to the SGR mess:
American Medical Association: Repeal the SGR, then “implement a five-year period of stable Medicare physician payments that keep pace with the growth in medical practice costs.” During that period, pilot “a new generation of payment models” (medical homes, for example), then transition to those that improve quality, care coordination and costs. The AMA also wants Medicare to permit balance billing — physicians charging Medicare beneficiaries for an amount above and beyond what the government program covers.
American Academy of Family Physicians: After SGR repeal, there would be a five-year transition to the patient-centered medical home. Primary-care physicians would receive a higher reimbursement rate than other specialties, and primary-care incentives included in the health-care overhaul law would be increased and extended.
American College of Surgeons: After SGR repeal, set a “realistic budget baseline” for future payment increases, ” which should “fairly reflect the costs of providing quality health care and are sufficient to preserve the patient-physician relationship and ensure patients have continued access to the physician of their choice.” During a five-year transition to different payment models, reimbursement growth would vary by service.
To my surprise, it’s the AMA that’s on to a nugget of something good: allow balance billing. Not a perfect solution, but it could be a major step towards something sustainable in the long run.
Somewhat less surprising is the willingness of the AAFP to double-down on the model that’s already failed them for so many years. It’s unfortunate. If primary care is going to be attractive to people like my classmates and me, the pay will have to be better, and the job will have to be better. Living an even more bureaucratic work experience and making a living that continues to be at Congress’s mercy aren’t on any medical student’s wish list.
I was originally going to abandon any effort to post the remainder of my coverage of the American Medical Students Association’s 2011 annual convention when it become clear that it would be so delayed that it could hardly be considered topical. A small number of readers have encouraged me to post the highlight anyways, using the arguments: better late than never; the events left to be blogged were the most interesting; and finally, I may as well “complete the chronicle.”
Below the cut, for those interested in how health policy was presented at the AMSA convention, are highlights from two events: a debate between Michael Cannon (Cato Institute) and Robert Zarr (American Academy of Pediatrics, Physicians for a National Health Plan); and a later event featuring Walter Tsou (immediate past president, PNHP).
For immediate release:
February 22, 2011
Washington, D.C. – The American Medical Association (AMA) announced late last night that it wholeheartedly supports the pro-union protest activities of certain physicians from the University of Wisconsin School of Medicine’s Department of Family Medicine.
Pro-union demonstrators — notably public school teachers — have flooded the state capital, Madison, to voice their displeasure with proposed cuts to pay, benefits, and collective bargaining ability. Meanwhile, a group of idealistic, enterprising physicians have set up shop to aid the protesters in their efforts. Given that these protests have been, fortunately, free from the violence wracking demonstrators in other parts of the world, these inspiring doctors have been using their special expertise for the benefit of the local protester community by writing the “sick notes” that will allow these teachers to keep their pay and jobs after having skipped work to attend the demonstrations.
They are, in short, ”providing real doctor’s notes for people who miss work.”
As has been captured in many of the videos of the protests, these heroic physicians have been able to assess their new ”patients” in mere seconds, doubtlessly utilizing the speed-H&P skills learned by practicing medicine under the AMA-supported system of RVU-based payment.
While some commentators have accused these doctors of ”stealing,” ”lying,” ”falling short of the public’s ethical expectations,” and ”demeaning the doctor-patient relationship,” the AMA would like to commend the work of these courageous physicians, who truly represent the best of American medicine and the future of primary care in this country. They truly are a shining example of what the AMA thinks that medical practice should be.
In addition to showcasing the near-lightspeed pace at which the AMA believes outpatient medicine should be practiced, these doctors — from unlicensed resident to grizzled veteran of community practice alike — exemplify the values that will need to become more commonplace if primary care in the United States is to be revitalized.
In 2007, the AMA’s Initiative to Transform Medical Education (ITME) released its Recommendations for Change in the System of Medical Education, concluding that the current shortage of primary care physicians in the United States is due to a cohort of medical students who are insufficiently altruistic, unwilling to be advocates for social justice issues, and too fixated on problem-solving and intellectual pursuits to be the effective community organizers that primary-care physicians ought to be.
In the view of the AMA, the model of ”primary-care-physician-as-community-organizer-for-social-justice” must replace the model of ”primary-care-physician-as-healer-and-problem-solver” for there to be a future for primary care in this country, especially given the reluctance of the federal government to increase physician payment under the AMA-supported RVU system.
As the voice of America’s doctors, and as the champions of primary care’s bright future as social justice advocacy, we are thrilled to see these Wisconsin physicians living up to the ideals espoused in the ITME recommendations, if not the Hippocratic Oath. The future of primary care is not in practicing medicine; it is in political agitation. These family practitioners are pioneering the way forward for their specialty. They are organizing for their community, and they are advocating for their patients’ sense of social justice, entirely unbound by the conventional problem-solving, clinical-assessment mentality that persists among primary care physicians at their own peril.
The American Medical Association stands with these brave primary care practitioners, and urges them to continue to practice primary care medicine in the best way possible. Only by following in their example can family physicians, outpatient internists, and pediatricians ”win the future” for their specialties in this environment of harsh RVU economics.
In case you haven’t realized by now, this is not an AMA press release. It is a satire/parody of the AMA’s positions on medical education and physician supply in the context of the primary care shortage. Use of the AMA name is protected fair use. For more disclaimers, see my ”About” page.
Like other enthusiasts of health policy, I spent plenty of time reading and thinking about the Wall Street Journal’s recent reporting on the RUC — the panel that decides how Medicare pays for physicians’ services. The existence of this system was news to many of my classmates, one of whom zeroed in on the hourly wage figures. By MedPAC’s calculation, radiologists would make approximately $193/hr if all of their work was paid at Medicare rates, compared to $101 for primary care physicians and $161 for surgeons.
Why, asked my classmate, should radiologists be paid so much relative to surgeons, given that the training length for diagnostic radiology and surgery is similar, and radiologists arguably play a smaller role in the care of an individual patient, face less malpractice risk (I might quibble with this, but I let it stand), and are able to work “better” hours, doing work that’s less physically demanding?
Now, the WSJ article helps to explain exactly how this situation has come about. The “market” for physicians’ services is one in which nominal and relative prices are set from above. They’ve been set in such a way that the “ROAD to happiness” starts with Radiology. (The “ROAD,” for those unfamiliar with the term, consists of Radiology, Ophthalmology, Anesthesiology, and Dermatology)
This lends itself to an interesting thought experiment. Would diagnostic radiologists fare this well under a market system? I think they would, and here’s why: I think that radiologists are medicine’s superstars, at least in an economic sense.
The reason that major-league athletes and Hollywood A-list celebrities command such high pay is not strictly because we as a society think they are individually more important than, say, an individual teacher or firefighter (or physician). It’s because these athletes and actors are in an industry where the consumer will pay a premium for the “best” (as opposed to minor league teams, indie movies, etc.), and in which many, many consumers can be reached at low marginal cost (cf. television, the internet). The athlete/actor doesn’t have to add a lot of value to a given person, but instead is compensated handsomely because he is able to add some amount of value to a lot of people who are willing to pay for it. Average class size in a public school may be 30, but most sports stadiums can fit tens of thousands, to say nothing of TV and radio audiences.
This strikes me as at least superficially similar to some aspects of diagnostic radiology. The use of medical imaging has exploded in the past 20 years, but it would be bold to claim that none of that increase has to do with the value that it adds to clinical decision-making and patient care (at least when used appropriately). And we as a society have decided that we want the best: that is to say, we want our scans read by radiologists.
What’s more, it’s entirely plausible that a diagnostic radiologist can add her full armamentarium of value to more cases per day than a physician in many other specialties. That it may take less time to read a scan doesn’t lessen the value added by having the scan read. The worth of the information to the patient is independent of the time it takes to derive it (within limits).
So, would radiologists still be on the ROAD in a market-based system of payment? The case in favour looks pretty good. Of course, the challenge facing American radiologists in my lifetime may not be justifying their value in patient care so much as justifying their value over and above their American-boarded Indian-based counterparts. Communications technology has helped make superstars of American radiologists… will it make them overpriced and obsolete as well?
Earlier this month, Dr. Bob Centor posted one in a long line of posts explaining the appeal and merits of retainer medicine, especially in the outpatient general medicine context. Retainer practices free both physicians and patients from the constraints of third-party payment systems, putting the patient firmly in control and allowing for the development of resilient physician-patient relationships that are more difficult to establish when visit length is otherwise effectively limited to 15 minutes (though these days I keep seeing “10 minutes” bandied about; is this a sign?).
What is fundamentally subversive about retainer practice, however, is that it represents a renunciation of dependence on government (or private insurers). So many primary care physicians in academia and the community still feel that the best way to “save” primary care is to run crying into Congress’s arms, to beg for even more money, and thus to enhance the dependence on Congressional whim that currently characterizes any practice that is largely dependent on Medicare or Medicaid.
As you might imagine, this wresting of autonomy tends to get some interest groups riled up.
But let’s look at retail clinics! Capitalizing on patient discontent with the current primary care model, these clinics have been expanding at a rapid clip, and are apparently doing a pretty good job of providing medical care. This may well be a desirable innovation in the provision of medical services, but that discussion is beyond the scope of this post. Perhaps what’s most surprising: many of them require patients to pay out of pocket without the possibility of insurane reimbursement. And patients do! Patients want to!
What this tells us is really what we knew already: primary care in the US is not working for patients. We knew that it’s not working for physicians either. It’s hard to see how stay-the-course pleading for government largesse is expected to work “this time, really!”
Of course, primary care doesn’t seem to capture much interest among medical students, either.
It’s interesting to think about these debates on how best to save primary care while reflecting on recent conversations with other first-year students. Somehow, through the crush of almost 200 now-forgotten introductions repeated over the course of the week, I managed to strike up a few conversations on preliminary specialty choice. Lots of students here, myself included, believe strongly in the importance and the role of primary care medicine. We just don’t want any part of it in the current system. What’s more, most of the classmates I asked weren’t entirely familiar with the concept of retainer practice, and it’s doubtful that we’ll be exposed to many role models who function in such a practice.
And that’s a shame. Orientation was full of lofty verbiage about role models and mentors. What better way is there to reinvigorate medical student interest in primary care than to expose them to role models who have chosen a practice structure that minimizes the hassles, overhead, and constraints of third-party payment, and instead is focused on what drew all of us to medical school in the first place: working for the patient?
While it’s too early to talk meaningfully about a specialty decision (though you’re more than welcome to start a betting pool…) it’s not too early for me to say this: the only way I would seriously consider paediatrics, general internal medicine, or family practice residency in the US is if the retainer model of practice is still viable when it comes time to decide (i.e. hasn’t been banned by law or marginalized by organized medicine).
Of course, I’m fortunate to have Canada as a relatively easy alternate option. And here’s the kicker. The phrase “lifestyle specialties” in the US usually refers to the “ROAD to happiness:” radiology; ophthalmology; anaesthesiology; and dermatology. [Medical students are big on the mnemonic acronyms] In Canada? Well, according to my own physician… it’s family practice.
So close together, but so many worlds apart.