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The outcomes of health care reform
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The health care reform bills moving through Congress measure 2,000 or more pages and have barely — if at all — been read by the members voting on our behalf. Even so, sweeping pronouncements are provided nightly on the television news about the bills’ wondrous benefits and the absent cost of such benefits. Although some viewers actually appear to believe the often contradictory statements being offered to soothe voters’ concerns, a growing majority of voters seem to doubt these claims and have come to believe that the present system is better than the probable outcomes of the reform process. Likely, this reflects a growing cynicism regarding the accuracy of governmental forecasts regarding its own proposals and programs. In this instance, the cynics are clearly more likely to be accurate than the forecasts.
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A central concern of the reform process has been cost containment. Chief among the costs to be contained are those benefits previously promised under prior Medicare legislation. As with all prior governmental health care programs, the costs of the Medicare program have ballooned some ninefold or more over those predicted by prior, pre-approval estimates. Thus, the need for cost containment becomes more pressing year by year. Since no politician concerned with re-election would dare propose or even vote for benefit reduction in Medicare, we are now regaled with tales of untold billions of dollars (present estimates equal $500 billion) wasted by fraud and abuse, just now discovered in a 40-year-old government program. Oddly enough, this money may be used to cover the expenses of still another health care benefit, only now being proposed.
Medicare fraud, waste and abuse
First and foremost, consultation with medical and surgical specialists seems to be the No. 1 source of that fraud, waste and abuse. At least that would be the interpretation of the recent hasty actions by the CMS to abolish consultation codes in the Medicare billing and payment system. So, although there may be other sources of fraud, waste and abuse that might be eliminated, clearly CMS has acted expeditiously to stamp out the No. 1 cause of such problems — specialists.
Why are specialists such a problem to Medicare?
Specialists order more tests and follow patients more closely than generalists, which drive up health care costs. Specialists may also use newer and more expensive branded rather than generic medications, further increasing health care costs. Worse, patients of specialists are often seen by their primary care and specialist doctors for the same conditions in the same year — yet another driver of increased cost. Specialists tend to hospitalize patients and follow them with interventions and procedures more than generalists. This still further increases costs of care. Finally, patients of specialists may even live longer than those not seeing specialists; this is especially true for cancer patients. This increases the total cost of care.
How can we stop this fraud, waste and abuse?
If specialty care is the leading cause of this $500 billion of Medicare fraud, waste and abuse, stopping it becomes an urgent priority — a priority that must be acted upon without waiting for Congress to act. Unfortunately, an outright denial of care is clearly likely to provoke an hostile voter reaction. Thus, eliminating consultation billing codes will produce a voluntary elimination of specialty consultants for patient beneficiaries. After all, if doctors are not paid for a service, they tend to provide less of that service to patients. Thus a simple change of billable payment mechanisms should reduce or eliminate unwanted and unnecessary consultations, thereby saving Medicare a considerable sum of money.
Elimination of consultation codes
As the economic equivalents of Newton’s third law of motion, there will be intended and unintended economic consequences to this action by CMS to eliminate consultation codes. These can be ascertained best by observation long after the action has occurred. Alternatively, we can survey the affected population to determine the actions planned in response to this action by CMS.
One such survey was conducted recently by the American Association of Clinical Endocrinologists (AACE), a professional organization of nearly 6,000 practicing, clinical endocrinologists. The results are predictable in terms of anticipated actions by clinicians in response to economic actions against their current clinical practice models. Twenty-two percent of responders believed this action would not likely change their hospital practice patterns, and the remaining 78% believed that this elimination of consultation billing codes would reduce or eliminate their willingness to see Medicare patients (53%) or even any patients (21%) in the hospital. Another 7% thought that they would stop using the hospital completely, and 4% declared that they would retire early. There was a similar impact on office practice as well, with 80% of respondents indicating that they would reduce or eliminate consultation availability for Medicare patients.
Thus, it seems clear from at least this AACE survey that the expectations of most recent Nobel laureates in economics who have worked in behavioral areas would be fulfilled, namely, that people will not work against their own economic self-interest. Instead, they will seek to maximize their gains. In this instance, it is perfectly predictable that elimination of consultation codes will reduce or eliminate consultation availability not only for Medicare but for all patients, especially in the hospital. However, while this may seem undesirable to many, it is likely to be the desired outcome in this instance.
Reducing consultations in the hospital and in the office will lower medical costs by reducing testing and procedures available for patients when ill. It furthers the myth that primary physicians can provide all the care that patients need, usually in very brief encounters. However, of greatest advantage is that this is self-rationing of care by the medical profession. As a consequence, governmental action is not seen as reducing or eliminating available medical care options to patients. Instead, it is the physicians themselves who are doing this. Such a mechanism protects the Congress and the federal bureaucracy from voter hostility and reprisals. Since the outlines of health care reform now project even more federally controlled restrictions on access and availability of health care, we can expect still more of this type of health care rationing, through limitations on physician actions.
It is interesting to note that the American Academy of Family Physicians has not objected to this elimination, perhaps because there is a small increase in established patient payments to offset the other larger reductions in consultations. This has become an established pattern of dealing with the medical community — namely, divide and conquer. Small personal financial benefits can be made to obscure larger issues of outside control of practice management and professional judgment. Nonetheless, the ultimate reduction in specialist availability will work against family physicians as well, at least in the long run.
But, these are limitations to which many physicians already voluntarily subscribe every time they write prescriptions determined by formulary limitations or provide prior authorization for consultations to specialists as are now required by some managed care organizations. Thus, by voluntarily limiting their professional options to those allowed by insurers, those physicians in reality are delegating a part of their professional judgment to those insurers. This is something never contemplated previously in the Hippocratic Oath. Those same physicians cannot now object when insurers, including Medicare, limit medical decision-making so that optimal health care becomes unobtainable. This becomes the ultimate endgame, and the implementers of this low-cost strategy become the medical profession, not the insurers and not the politicians.
Alan J. Garber, MD, PhD, is a member of the Cardiology Today Editorial Board and Chief Medical Editor of its sister publication Endocrine Today.
Perspectives from Cardiology Today Editorial Board members on outcomes of health care reform
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Cardiologists as well as endocrinologists share Dr. Garber’s dismay regarding the CMS decision to eliminate consultation codes. We feel insulted more by the lack of appreciation of the nature of the important work we do as physicians helping one another help patients as we are by the change in payment. Elimination of the consultation codes is law of the land regardless of what Congress ultimately decides about health care reform legislation, and is but a harbinger of things to come. We do not yet know what will actually be in the ‘sausage’ now being made in Washington, D.C., but it is clear that we are in the midst of a sea-change in the way we deliver health care in the United States, including fundamental changes in traditional fee-for-service medicine and in reliance on individual physicians practicing as independent businessmen and women. The cost and complexity of modern medicine requires a change in our delivery systems. Change is needed. Change is inevitable. We physicians need to stick together regardless of our specialty to ensure that our patients get high-quality care, to shape change rather than resist it.
– Samuel L. Wann, MD
Cardiology Today Editorial Board Section Editor
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I read with interest Dr. Garber’s comments on the possible implications of health care reform. I agree with much of what he says. However, I doubt that Medicare in the end will eliminate consultation codes since specialty input into patient care has become an essential element in our litigious society. In my opinion, there is indeed staggering waste in our health care system. Furthermore, I do not believe that fraud constitutes a major problem here despite governmental assertions that it is a major issue. If I had written the health care bill currently before Congress, I would have made tort reform a major tenet. I believe that the enormous waste in our health care system is the result of defensive medicine. I see literally tens of thousands of dollars wasted every day for unnecessary testing and unnecessary hospitalizations because of the fear of litigation. If we corrected that flaw in our system, health care costs would plummet.
– Joseph S. Alpert, MD
Cardiology Today Editorial Board member
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Dr. Garber has written a very provocative and insightful piece on the potential implications of some of the elements of health care reform being discussed and enacted. Everyone agrees that some degree of cost containment is necessary, as the current growth rate of health care costs is not sustainable. The challenge is how to do that in a way that provides excellent and timely care; that preserves the doctor-patient relationship; and that is fair to the gamut of health care providers. Outside of the United States, health care rationing in publicly funded health care has been accepted as necessary, but it is unlikely that we will engage in such a debate in the United States — at least not explicitly. The valid concern that Dr. Garber raises is that physicians may unwittingly become engaged in rationing disguised as reform, and that would indeed be a tragedy.
– Deepak L. Bhatt, MD
Cardiology Today Editorial Board member