A new article in New England Journal of Medicine probes how we got to this situation in the first place: Why are Medicare costs growing faster than Congress predicted they would back in the late 1990s? What created the gap between how much we budget for Medicare and how much we spend on the program?
It mostly comes down to a handful of medical specialities that have grown much faster than expected. Some parts of the Medicare system have actually grown slower than expected. All of them, however, would face a double-digit cut in reimbursements if Congress doesn’t appropriate any additional money to the Medicare program.
Harvard health policy researchers Ali Alhassani, Amitabh Chandra and Michael Chernew draw up the above chart to explore how much various medical specialities either overshot or came in under Medicare spending targets. Radiation oncology, for example, overshot what we expected it to cost by just about 300 percent. General surgery, however, has actually cost much lower than expected while opthalmology is just about on target.
There’s a hole between how much we budget for Medicare and how much it costs, because way more medical specialities are to the right of the dotted line here than to the left.
This graph also speaks to the doc-fix as a relatively inelegant policy solution: If Congress passes a pay-patch, all doctors see their salaries remain steady. If they don’t, all face a 27.4 percent reduction in reimbursement, regardless of whether their costs have actually outpaced the Medicare budget. “Across-the-board cuts in fees are too blunt an instrument to restrain the growth of spending on physician services,” the Harvard researchers argue. In other words, it’s hard to push general surgeons to keep costs down — as this chart shows they have — if, at the end of the day, their only reward will be a double-digit pay cut along with everyone else.
Source: Washington Post
But, as I look back, the Skin Horse was right – Real is a process, bit by bit, day by day. Over the years, residency has taken its toll, the wrinkles are there, my hair has been loved off, and the memories of all of my patients – through life, death, and everything in between – are present in me, subconsciously affecting my decisions at each critical moment. And real hurts, too – more than you would imagine. And no one ever said it was easy. It is scary sometimes. Sad sometimes, too.
Efforts to improve the effectiveness of health care, and contain its cost, have produced a number of innovations designed to help us more easily shoulder some of our new responsibilities for our health.
But those of us who have yet to recognize the tasks that are now ours often mistake those “patient-centered” innovations as new barriers between us and the help we need.
One of the big issues I see in IM residencies is that our graduates that don’t choose subspecialties are increasingly becoming hospitlalists, to the detriment of the primary care workforce.
That’s all fine and well, as we need good hospitalists, it’s a growth field (for now) and it pays relatively well.
But what happens in 2014 when there simply aren’t enough PCPs around?
While a lot of the current debate is around how much government and what kind of government (I’ll leave that to the political pundits), I’ve been fascinated with the growing movement of businesses (yes, “big bad businesses”!) that are tackling complicated societal problems.
I WANT people to recognize that spending money when there’s no clue to the charge (not cost, charge) is directly responsible for a ton of the runaway cost in medicine.
Tiered hospital networks are a good way to save costs and improve quality. Before mindlessly bashing health plans, it’s worthwhile to look into some of the finer points.
Ungar’s position is that healthcare costs have to be reigned in from the supply (ie, provider) side, and that it isn’t effective to expect patients to drive down costs from their side.
Hixon argues that patients with more financial responsibility for their own care do indeed make better decisions regarding efficient use of healthcare dollars. Furthermore, he cites a study that found that patients with high deductible health insurance policies (eg, HSA qualified plans) had more preventive care, lower rates of hospitalization, and were more compliant in terms of following their doctors’ recommendations. They were also more likely to question their medical bills and had overall lower medical costs than people with traditional low-deductible policies.
Since Canada came along
Over email, some far-flung EM colleagues and I were discussing a case, where an elderly but generally healthy man developed a fever, went to an emergency department, had blood cultures drawn (as well as other labs, films and urine). Ultimately the old man was discharged home.
A few days later, on a weekend, a positive blood culture report (gram negative rods) prompted another ED attending on duty to call the patient at home. Over the phone, the patient said he felt fine; back to normal, no worse for wear. The ED attending considered the matter closed.
On Monday, the primary care doc reviewed the case, and, with ID, admitted the patient (who still felt fine) to the hospital for monitoring and IV antibiotics. Apparently a nastygram was sent to the weekend ED attending, as well, citing some kind of policy that gram negative rods can’t be ignored.
My friend, the Canadian Doctor, commented:
This is ridiculous. Because of the “unique” medico-legal climate in the US, there will never be an incentive for any physician to endorse conservative, less aggressive management. Without the support of colleagues from other specialties for anything but aggressive knee-jerk responses, patients suffer the consequences of a peer-pressured physician environment where we must all cave to the most conservative (brainless) approach. While I am comfortably protected in Canada (and its different set of imperfections, of course), I hope that this American death spiral of false logic and spineless non-decision making is arrested soon by some tort reform and financial accountability.
In the past I’ve really tried to shy away from policy discussions on this blog. There are already great sites for that sort of thing, and I don’t want my words taken out of context or brought back to haunt me.
But I did tell my Canadian friend that his emailed paragraph was delicious enough to deserve a wider audience. With a few minor alterations, he’s ok’d its appearance, here.
It’s difficult to predict what kind of effect collecting and publicizing these numbers will have on ED boarding and crowding.