Uninsured Adults: Myth vs. Reality

[mlw47]

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Uninsured Adults Presenting to US Emergency Departments
.[FONT=verdana, arial, helvetica, sans-serif]Assumptions vs Data .
[FONT=verdana, arial, helvetica, sans-serif] Manya F. Newton, MD, MPH, MS; Carla C. Keirns, MD, PhD, MA, MS; Rebecca Cunningham, MD; Rodney A. Hayward, MD; Rachel Stanley, MD, MHSA .

[FONT=verdana, arial, helvetica, sans-serif] JAMA. 2008;300(16):1914-1924.
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http://jama.ama-assn.org/cgi/content/short/300/16/1914


[FONT=verdana, arial, helvetica, sans-serif] Context Emergency departments (EDs) are experiencing increased patient volumes and serve as a source of care of last resort for uninsured patients. Common assumptions about the effect of uninsured patients on the ED often drive policy solutions..
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[FONT=verdana, arial, helvetica, sans-serif]Objective To compare common unsupported statements about uninsured patients presenting to the ED with the best available evidence on the topic..
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[FONT=verdana, arial, helvetica, sans-serif]Data Sources OVID search of MEDLINE and MEDLINE in-process citations from 1950 through September 19, 2008, using the terms (Emergency Medical Services OR Emergency Service, Hospital OR emergency department.mp OR emergency medicine.mp OR Emergency Medicine) AND (uninsured.mp OR medically uninsured OR uncompensated care OR indigent.mp OR uncompensated care.mp OR medical indigency)..
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[FONT=verdana, arial, helvetica, sans-serif]Study Selection Of 526 articles identified, 127 (24%) met inclusion/exclusion criteria. Articles were included if they focused on the medical and surgical care of adult (aged 18 to <65 years) uninsured patients in emergency settings. Excluded articles involved pediatric or geriatric populations, psychiatric and dental illnesses, and non–patient care issues..
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[FONT=verdana, arial, helvetica, sans-serif]Data Extraction Statements about uninsured patients presenting for emergency care that appeared without citation or that were not based on data provided in the articles were identified using a qualitative descriptive approach based in grounded theory. Each assumption was then addressed separately in searches for supporting data in national data sets, administrative data, and peer-reviewed literature..
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[FONT=verdana, arial, helvetica, sans-serif]Results Among the 127 identified articles, 53 had at least 1 assumption about uninsured ED patients, with a mean of 3 assumptions per article. Common assumptions supported by the evidence include assumptions that increasing numbers of uninsured patients present to the ED and that uninsured patients lack access to primary care. Available data support the statement that care in the ED is more expensive than office-based care when appropriate, but this is true for all ED users, insured and uninsured. Available data do not support assumptions that uninsured patients are a primary cause of ED overcrowding, present with less acute conditions than insured patients, or seek ED care primarily for convenience..
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[FONT=verdana, arial, helvetica, sans-serif]Conclusion Some common assumptions regarding uninsured patients and their use of the ED are not well supported by current data. .

[FONT=verdana, arial, helvetica, sans-serif] Author Affiliations: Robert Wood Johnson Clinical Scholars Program, University of Michigan School of Medicine, Ann Arbor (Drs Newton, Keirns, and Hayward); Department of Emergency Medicine (Drs Newton, Cunningham, and Stanley) and Division of General Medicine, Department of Internal Medicine (Drs Hayward, Newton, and Keirns), University of Michigan Medical Center, Ann Arbor; Department of Emergency Medicine, Hurley Medical Center, Flint, Michigan (Drs Newton, Cunningham, and Stanley); Department of Health Management and Policy, University of Michigan School of Public Health, Ann Arbor (Drs Newton, Hayward, and Cunningham); and Veterans Affairs HSR&D Center of Excellence, Ann Arbor VA Health System (Drs Hayward and Keirns). .

 

[BADMD]

All this paper shows is that there are assumptions about overcrowding made in 53 of 127 papers. That they exclude psychiatric, dental and non-patient care emergency issues seems ludicrous, as those are exactly the patient population that inappropriately utilize the ED. Additionally, just because an assumption is made, doesn't mean it isn't true.

Patient volume and insurance make up are going to be heavily dependent on economics and the local social climate. Any study on this topic which uses data that isn't "right now" is hopelessly flawed.

An ED around me closed. One of the surrounding hospitals has had a dramatic increase in its ED census. Those patients have been heavily weighted towards the uninsured. I don't know if the acuity has changed, but the volume certainly has.

This seems to me to be a feel good attempt to not "blame" overcrowding on the uninsured. And from that prospective, I have to agree. The problem isn't the uninsured, the problem is a system (CMS) that greatly rewards specialist and procedure based medicine. This has resulted in fragmentation of the system.

Because of this, the ED represents and attractive option to the insured and uninsured a like. With less than a 12 hour wait, you have access to immediate lab results, advanced diagnostic imaging (with a result in hours not days), rapid specialist access and a physician who will evaluate you and coordinate care. Even with a higher co-pay, it makes sense that someone with an acute or sub-acute problem would choose ED evaluation before turning to their doctor.

What the uninsured do is add to volume, without providing revenue to expand services as needed. More patient take more nursing and physician time, but if you can't pay for more, you have to do more with less. If you tack on the inability to see a PCP, without outlaying cash upfront, then you do get a larger scope of ED visits. Are these assumptions? Sure, but that doesn't mean it is wrong for everyone. "The problem" goes beyond one group.

 

[mlw47]

The problem isn't the uninsured, the problem is a system (CMS) that greatly rewards specialist and procedure based medicine. This has resulted in fragmentation of the system.

I think that's one of the points that the authors were trying to make.

This just be my naive med student sympathies talking, but I agree, the point of the paper is to deflect the anger off of the uninsured and onto the persons/organizations that deserve more of the blame (ie. the "system"). It seems fair to be angry about the way EDs are abused, but it's only productive if the anger is directed at the people who deserve it. That's why I thought this paper was worth reading...it helps clarify that point.


Someone else have a comment?

 

[GSresident]

I think that's one of the points that the authors were trying to make.

This just be my naive med student sympathies talking, but I agree, the point of the paper is to deflect the anger off of the uninsured and onto the persons/organizations that deserve more of the blame (ie. the "system"). It seems fair to be angry about the way EDs are abused, but it's only productive if the anger is directed at the people who deserve it. That's why I thought this paper was worth reading...it helps clarify that point.


Someone else have a comment?

I'm not sure I get the logic here. You make assumptions that don't seem to be based on fact but rather opinion. You claim that specialists are overpaid. Based on what? How is it that you decided that specialists are overpaid? Why is it you that decides that specialists are overpaid? So if we accept your assumption that specialists are overpaid, then we are supposed to do some other magical thinking to decide that specialist overpayment is causing crowded ER's?

Having moonlighted for years in the ER setting, let me tell you about the real world. Lets have a little play.

Setting: Rural ER in Kentucky. Its Sunday afternoon.

Nurse to ER doc: Oh no, the Jones' just showed up.
ER doc: What does that mean?
Nurse: They always bring in like 14 kids and both of them come in.
ER Doc: Well they're going to have to wait, there are only 4 beds. One of them has an MI, another has a broken ankle, and the other has a COPD exacerbation with a sat of 75.
Nurse: The last time we did that they complained to administration and they gave them a $500 gift certificate to Denny's. It came out of our budget.
ER Doc: Alright pack them into room 4.
Nurse: I'll have to make charts up for all 14.
ER Doc: What?
Nurse: 5 of the kids are sick and mom wants the rest of them seen. Also the mom thinks she might be coming down with a cold too. The baby dady of 3 of them is complaining of back pain.
ER doc: Doesn't he have a primary care physician that writes RX's for all that?
Nurse: Yes but someone saw him out hunting and turned him into social services. They are in the process of yanking his disability so he has to make a good show of having back pain.
ER doc: Good Christ!
Nurse: Oh and start writing RX for tylenol right now.
ER Doc: thats an over the counter medication.
Nurse: I know but the state will pay for it if you write a RX.
ER doc: I'm not writing 14 RX for tylenol. They can just go buy a bottle like I have to if I need it.
Nurse: The last time an ER doc refused them they complained to the state medical board and he had to go to a hearing about it. I think they gave him probation or something but he got suspended privileges at this hospital.

And it goes on and on. That is reality my friend. It happened OVER and OVER and OVER again. If it wasn't the Jones' it was the Hernandez's or the McCalsky's. Don't hate on specialists because they are playas. Hate on the actual people who are abusing the system.

 

[BADMD]

I'm not sure I get the logic here. You make assumptions that don't seem to be based on fact but rather opinion. You claim that specialists are overpaid. Based on what? How is it that you decided that specialists are overpaid? Why is it you that decides that specialists are overpaid? So if we accept your assumption that specialists are overpaid, then we are supposed to do some other magical thinking to decide that specialist overpayment is causing crowded ER's?

What the heck are you talking about? I don't think anyone said that specialists are overpaid. What I did say is that the payment structure rewards procedures and specialist referrals, which has fragmented the way medicine is delivered. These are quite different.

Having moonlighted for years in the ER setting, let me tell you about the real world. Lets have a little play.

Setting: Rural ER in Kentucky. Its Sunday afternoon.

Nurse to ER doc: Oh no, the Jones' just showed up.
ER doc: What does that mean?
Nurse: They always bring in like 14 kids and both of them come in.
ER Doc: Well they're going to have to wait, there are only 4 beds. One of them has an MI, another has a broken ankle, and the other has a COPD exacerbation with a sat of 75.
Nurse: The last time we did that they complained to administration and they gave them a $500 gift certificate to Denny's. It came out of our budget.
ER Doc: Alright pack them into room 4.
Nurse: I'll have to make charts up for all 14.
ER Doc: What?
Nurse: 5 of the kids are sick and mom wants the rest of them seen. Also the mom thinks she might be coming down with a cold too. The baby dady of 3 of them is complaining of back pain.
ER doc: Doesn't he have a primary care physician that writes RX's for all that?
Nurse: Yes but someone saw him out hunting and turned him into social services. They are in the process of yanking his disability so he has to make a good show of having back pain.
ER doc: Good Christ!
Nurse: Oh and start writing RX for tylenol right now.
ER Doc: thats an over the counter medication.
Nurse: I know but the state will pay for it if you write a RX.
ER doc: I'm not writing 14 RX for tylenol. They can just go buy a bottle like I have to if I need it.
Nurse: The last time an ER doc refused them they complained to the state medical board and he had to go to a hearing about it. I think they gave him probation or something but he got suspended privileges at this hospital.

And it goes on and on. That is reality my friend. It happened OVER and OVER and OVER again. If it wasn't the Jones' it was the Hernandez's or the McCalsky's. Don't hate on specialists because they are playas. Hate on the actual people who are abusing the system.

Your scenario, though annoying when it occurs and ludicrous at the end, is not the reason for over crowding. I think if you spend some time looking into the economics of healthcare delivery and understand how economics drives the choices people make, you'll have a better understanding of the overcrowding issue.

 

[GSresident]

What the heck are you talking about? I don't think anyone said that specialists are overpaid. What I did say is that the payment structure rewards procedures and specialist referrals, which has fragmented the way medicine is delivered. These are quite different.

Actually what you said was this:

The problem isn't the uninsured, the problem is a system (CMS) that greatly rewards specialist and procedure based medicine. This has resulted in fragmentation of the system.

If I take it at face value, you are saying that ER's are overcrowded because ER docs refer the care to specialists because the specialists are paid well for procedures. Lets say for a second that we accept this premise as a cause for ER overcrowding. What then is the solution if the problem is that the system "greatly rewards specialists?" I doubt very seriously whether your reply would honestly be "keep the reimbursement of specialists the same or increase it." To say that would defy even the magical thinking it takes to assume that greatly rewarded specialists is the reason for ER crowding.

I don't suppose you realize that the code for simple repair of laceration to the face <2.5cm, 12011, pays the exact same amount if the ER doc sews it up or a plastic surgeon sews it up. To be precise, the procedure is awarded 2.72 RVU's in the ER, or $96.26. It is not even worth 30 seconds of my time to drive in and sew that up for you. Apparently the ER docs have figured out that it doesn't pay crap to sew it either, so instead of getting off their fat asses and sewing it up, they keep playing solitaire and call a plastic surgery consult for the 1 cm laceration on the cheek of a 96 year old man. Specialists aren't paid any better for the same procedure or service by CMS than an FP is. I'm sorry but that is a fact which cannot be disputed.

Because of this, the ED represents and attractive option to the insured and uninsured a like. With less than a 12 hour wait, you have access to immediate lab results, advanced diagnostic imaging (with a result in hours not days), rapid specialist access and a physician who will evaluate you and coordinate care. Even with a higher co-pay, it makes sense that someone with an acute or sub-acute problem would choose ED evaluation before turning to their doctor.

I get that. But having actually worked in an ER, it was my experience that insured people generally tried to go to the doctor during business hours if possible and would only come into the ER at night or on weekends if they got sick. That isn't to say that there weren't insured people abusing the system, but from the mix I saw it was mostly the uninsured abusing the ER as a primary care office.

Maybe instead of cutting reimbursement to specialists, CMS should increase the RVU's of office visits so that PCP's would actually take new medicare patients or even the occasional uninsured patient. The way it is now, PCP's actually lose money seeing medicare patients and make up the difference with insured patients. What incentive would a PCP have to take new patients that she would lose money on? Furthermore, why would she further add to the problem by taking uninsured patients?

I think if you spend some time looking into the economics of healthcare delivery and understand how economics drives the choices people make, you'll have a better understanding of the overcrowding issue.

Again you are making an assumption. I am extremely well versed on the economics of healthcare delivery and I could probably write a 1000 page book on the subject. That being said, I do not feel that my personal credentials are germane in any way to the discussion. To use my credentials as a reason to believe what I am saying would be argumentum ad verecundiam.

 

[docB]

Let's try to keep this civil.

I think the argument being made was more along the lines of the current reimbursement structure creating incentives for docs to choose to go into procedural specialties rather than primary care and that that may be a cause of overcrowding because there are not enough primary care docs. No one said we should cut specialist pay. I agree with you that it would be better to increase PMD pay.

 

[BADMD]

If I take it at face value, you are saying that ER's are overcrowded because ER docs refer the care to specialists because the specialists are paid well for procedures.

Actually, that is not at all what I'm saying at all. That is kind of a bizarre conclusion, frankly.

The issue is that medical students don't want to be primary care doctors. Based on the way CMS pays, it is much more lucrative to be a procedural heavy specialist than it is to be a cognitive based specialist. Moreover, in order to see the ungodly number of patients one needs to see in order to make money as a PCP, it is generally more lucrative to send complex patients to have each organ system picked apart by the relative subspecialist, than it is to spend the time to do it themselves.

The same thing occurs for emergency and acute care. It is not in the PCPs best interest to see anything that acute: they have to bump other patients, may spend large amounts of time with that one patient and aren't going to get paid very well for it. And that even assumes that the PCP even has the ability to see a patient on short notice. When it takes 1-2 months to get an appointment, getting seen same day or next day can be impossible. Fortunately, most PCPs try to see their own, less sick patients in the ED, but many patients don't even try. It takes less time to be seen in the ED, even including a huge wait, then it is call, get an appointment and then get seen in the office.

What then is the solution if the problem is that the system "greatly rewards specialists?" I doubt very seriously whether your reply would honestly be "keep the reimbursement of specialists the same or increase it."

The solution is to pay the cognitive services at a higher rate. That would include cognitive services to specialists too. It would make primary care more attractive and would encourage specialists to evaluate, diagnose and treat patients, as opposed to wanting to only do things too them.

I don't suppose you realize that the code for simple repair of laceration to the face <2.5cm, 12011, pays the exact same amount if the ER doc sews it up or a plastic surgeon sews it up. To be precise, the procedure is awarded 2.72 RVU's in the ER, or $96.26. It is not even worth 30 seconds of my time to drive in and sew that up for you. Apparently the ER docs have figured out that it doesn't pay crap to sew it either, so instead of getting off their fat asses and sewing it up, they keep playing solitaire and call a plastic surgery consult for the 1 cm laceration on the cheek of a 96 year old man. Specialists aren't paid any better for the same procedure or service by CMS than an FP is. I'm sorry but that is a fact which cannot be disputed.

Ignoring your obvious vitriol and given that you've completely misunderstood the point, I'm not sure why the EPs you are dealing with would pass up on a simple laceration like that. Frankly, if you happen to be in house, I'm not sure why you would pass on it either. That is some of the quickest money you'll make. I suspect that your EPs are paid by the hour and don't see any of their RVUs. Which actually proves my point to a certain degree.

See the patient and acquiring proper documentation for this simple lac that you describe will get me 1.34 RVUs. It will take me less time to sew it and get 2.72 RVUs than it takes for me evaluate it and ensure follow up care. I can get even more RVUs if I can do a regional block. I'd actually rather be the "designated sewer" and just do small lacerations all day than evaluate the laceration and then sew it. Why? The procedure pays more than the evaluation.

I get that. But having actually worked in an ER, it was my experience that insured people generally tried to go to the doctor during business hours if possible and would only come into the ER at night or on weekends if they got sick.

I don't know what kind of community you are practicing in, but many insured patients use the ED as an all hours clinic. If you have a 9-5 job and can't take any time off, you end up in the ED for minor things. It is also much easier to do a "one stop shop" in the ED, rather then see your own doctor, get a referral for a test, schedule the test, go back for the result, then cover next steps. All those can be taken care of, many times, in a few hours in the ED. Not that the uninsured don't abuse the ED, but many insured use it inappropriately as well.

Maybe instead of cutting reimbursement to specialists, CMS should increase the RVU's of office visits so that PCP's would actually take new medicare patients or even the occasional uninsured patient.

Which is exactly what I've been saying the whole time. I just used different words. Although given the pool of money from CMS is finite, increasing pay for cognitive services is cutting the pay of procedural services, hence why the specialists are generally against it.

 

[GSresident]

The issue is that medical students don't want to be primary care doctors. Based on the way CMS pays, it is much more lucrative to be a procedural heavy specialist than it is to be a cognitive based specialist. Moreover, in order to see the ungodly number of patients one needs to see in order to make money as a PCP, it is generally more lucrative to send complex patients to have each organ system picked apart by the relative subspecialist, than it is to spend the time to do it themselves.

The same thing occurs for emergency and acute care. It is not in the PCPs best interest to see anything that acute: they have to bump other patients, may spend large amounts of time with that one patient and aren't going to get paid very well for it. And that even assumes that the PCP even has the ability to see a patient on short notice. When it takes 1-2 months to get an appointment, getting seen same day or next day can be impossible. Fortunately, most PCPs try to see their own, less sick patients in the ED, but many patients don't even try. It takes less time to be seen in the ED, even including a huge wait, then it is call, get an appointment and then get seen in the office.

Agreed. That is a huge problem and contributes to the ER overcrowding.

The solution is to pay the cognitive services at a higher rate. That would include cognitive services to specialists too. It would make primary care more attractive and would encourage specialists to evaluate, diagnose and treat patients, as opposed to wanting to only do things too them.

Sure pay the E&M codes higher. It would pay more for a consult. We use the exact same E&M codes as you do. The problem is you would have to raise the RVU's of each of the codes in order to pay them higher. That would be difficult because you would have to declare by fiat that it takes more resources and training to see a patient and evaluate than it does to do an 8 hour surgery on them.

Frankly, if you happen to be in house, I'm not sure why you would pass on it either. That is some of the quickest money you'll make. I suspect that your EPs are paid by the hour and don't see any of their RVUs. Which actually proves my point to a certain degree.

If I am in the hospital I am operating and I can't leave the OR to go to the ER to do someone else's job for him. And btw, I can make $96 in about 15 seconds in my office and not have to deal with screaming toddlers and pushy parents. Furthermore, I will have been paid up front for the $96 and I absolutely will not get stiffed.

Here is what ER call means to a plastic surgeon:
1) It involves me driving into the ER either away from the office with more profitable patients or away from family. My family time is worth more to me than the $96 I would get for a 1/2 hour drive into the ER, the 1/2 hour I would spend seeing the patient and fixing them and the 1/2 hour I would take driving home. And the $96 I would make depends on whether they have insurance (they probably don't) and whether their insurance company would actually pay me (about %40 of the time).
2) It involves injecting uncertainty into my life which I will not tolerate.
3) Because of the EMTALA rules, ER call involves the force of law, which inevitably means the force of a gun. I will not deal with people who try to force me into an activity. All the ER doc would have to do is ask me to help him and I would gladly go to help a brother out. But when the ER doc demands it because of EMTALA, he is essentially pointing a gun at me, which means that I point the middle finger up at the clouds.

See the patient and acquiring proper documentation for this simple lac that you describe will get me 1.34 RVUs. It will take me less time to sew it and get 2.72 RVUs than it takes for me evaluate it and ensure follow up care. I can get even more RVUs if I can do a regional block. I'd actually rather be the "designated sewer" and just do small lacerations all day than evaluate the laceration and then sew it. Why? The procedure pays more than the evaluation.

Local anesthesia is included in almost all of the laceration repair codes, so forget about that regional block. As stated above, I would rather not be the "designated sewer."

I don't know what kind of community you are practicing in, but many insured patients use the ED as an all hours clinic. If you have a 9-5 job and can't take any time off, you end up in the ED for minor things. It is also much easier to do a "one stop shop" in the ED, rather then see your own doctor, get a referral for a test, schedule the test, go back for the result, then cover next steps. All those can be taken care of, many times, in a few hours in the ED. Not that the uninsured don't abuse the ED, but many insured use it inappropriately as well.

Many insurance plans have huge disincentives to utilizing the ER that way so honestly I see very few insured patients utilizing the ER as a PCP. By comparison, the uninsured have absolutely no disincentive built in to their 'no pay' plan for using the ER. Furthermore, I really can't think of any doctors, PCP's or specialists, who will allow people to walk into their office and receive free care. Payment is demanded up front in almost all cases I've seen. So the uninsured really can't, in most cases, go to a PCP without cash in hand and they know it. Also they know that they can't be refused in an ER, even for non-emergent problems. So you see there really is a perfect storm driving the uninsured into the ER. They have every incentive to utilize the ER in that way. When you give people an incentive to do something, they make it happen.

Which is exactly what I've been saying the whole time. I just used different words. Although given the pool of money from CMS is finite, increasing pay for cognitive services is cutting the pay of procedural services, hence why the specialists are generally against it.

Again, to cut the fee for procedures, you would have to declare by fiat that it takes less resources to deliver a procedure. You don't see the problem with that? Also what about the rarity of the specialty and the hell one has to go through to get specialized? Did you know that they make only about 180 plastic surgeons in the country each year? Do you have any concept of how difficult a general surgery residency is? How about ortho? Neurosurgery? Ophtho?

When a neurosurgeon was in medical school, he had to smoke all of you on the test or he wouldn't get to be a neurosurgeon. The neurosurgeon sacrificed more in medical school than the guy who was just coasting by to get a family practice spot. Then when it came time for the match, the neurosurgeon was sweating his ass off because of how incredibly difficult it is to match into neurosurgery, while the PCP guy was basically assured a spot because they give out FP residencies like candy. If the neurosurgeon was lucky enough to match, he then had to go through an absolute hell of a residency, 7 years or more in length. The FP was in practice for 4 or 5 years at least by the time the neurosurgeon graduated. And here is the real kicker - the neurosurgeon can do family practice. The family practitioner can't do neurosurgery. So then, do you think it unreasonable for the neurosurgeon to get a little miffed when the 'easy way out' PCP doc complains about how much money he makes?

 

[BADMD]

The family practitioner can't do neurosurgery. So then, do you think it unreasonable for the neurosurgeon to get a little miffed when the 'easy way out' PCP doc complains about how much money he makes?

This isn't about how hard stuff is, this is about economics. Want more PCPs? Then you have to pay them more. That pay has to come from somewhere. This is the same argument that airline pilots make. Yes, it is tough to be a pilot and yes it costs a lot, but if you can't fill the plane, because tickets costs too much, then it doesn't really matter how much that pilot thinks he is worth.

You want to shift medical students into primary care, then you have to make primary care attractive enough to keep them out of the procedure based specialties. As a society, we want to make it so that those medical students who can be neurosurgeons actually want to consider primary care. That will take a shift in how we pay for things.

 

[GSresident]

This isn't about how hard stuff is, this is about economics. Want more PCPs? Then you have to pay them more. That pay has to come from somewhere. This is the same argument that airline pilots make. Yes, it is tough to be a pilot and yes it costs a lot, but if you can't fill the plane, because tickets costs too much, then it doesn't really matter how much that pilot thinks he is worth.

First, it is about how tough it is to become a specialist. It is also about the fact that there are, by definition, fewer people capable of providing the service, thus creating scarcity. Even in our pseudo-socialized healthcare system, the reality of scarcity plays a role. In 2008 there were 255 pro-football players drafted into the NFL. During that same year, ~170 neurosurgeons were produce in the US. Yes the talent is that rare. Yes it is that extraordinary to be a neurosurgeon and yes they deserve to be compensated accordingly.

In the situation of a pilot, you are talking about a negotiation between the pilots/unions/etc. and the airlines. This is done with the possibility of reaching a compromise agreeable to both sides. It also is implied that one or the other side can say no and walk away. Arbitrarily lowering specialist reimbursement is not the same thing as a negotiation. One situation involves the right of a negotiator to back out, the other involves putting a gun to someone's head and saying 'you want to sign on the dotted line don't you?'

Furthermore, you have not convinced me that the desire to lower specialist reimbursement is anything other than a move to soothe jealousy and feelings of inadequacy. You also have not shown that decreasing specialist reimbursement would do anything about the ER overcrowding.

You want to shift medical students into primary care, then you have to make primary care attractive enough to keep them out of the procedure based specialties. As a society, we want to make it so that those medical students who can be neurosurgeons actually want to consider primary care. That will take a shift in how we pay for things.

I'm not sure I want to shift medical students into primary care. There are so extremely few people capable of becoming neurosurgeons that to take a neurosurgeon out of the pool would be far more damaging than taking an FP out of the pool. How many neurosurgeons are there in the entire state of South Dakota? Would you like to get in an accident there and develop a head bleed? Even with life flight would you likely suffer much more severe disability or even death because of the unavailability of a neurosurgeon. Don't believe that will have an economic impact? Why don't you ask a hospital what happens when they lose that coveted level 1 trauma center designation?

If you want more FP's, the way to do it is not to punish the most capable people for being capable. That is like saying if you want more workhorses you should hamstring all race horses. One thing you could do to solve the problem would be to stop all of the nonsense of producing physicians who don't really want to work more than 20 hours a week. Why spend the resources producing 3 physicians who will do the work that used to be done by 1? You know exactly what I am talking about and exactly who I am talking about unless your head is buried under 30 feet of self-deluding sand. All of that social engineering BS of the early 90's has consequences. Feel it. Love it. Pay for it.

Here is the crux of the issue for ER overcrowding:

Many insurance plans have huge disincentives to utilizing the ER that way so honestly I see very few insured patients utilizing the ER as a PCP. By comparison, the uninsured have absolutely no disincentive built in to their 'no pay' plan for using the ER. Furthermore, I really can't think of any doctors, PCP's or specialists, who will allow people to walk into their office and receive free care. Payment is demanded up front in almost all cases I've seen. So the uninsured really can't, in most cases, go to a PCP without cash in hand and they know it. Also they know that they can't be refused in an ER, even for non-emergent problems. So you see there really is a perfect storm driving the uninsured into the ER. They have every incentive to utilize the ER in that way. When you give people an incentive to do something, they make it happen.

Making more FP's won't do anything to keep the uninsured out of the ER. It will just mean there are more FP's. Cutting the pay of specialists will not do anything for the uninsured because they can't afford specialists anyway. It will just mean that less specialists will accept insurance, which will hurt both the insured and the uninsured.

 

[EdibleEgg]

And here is the real kicker - the neurosurgeon can do family practice. The family practitioner can't do neurosurgery. So then, do you think it unreasonable for the neurosurgeon to get a little miffed when the 'easy way out' PCP doc complains about how much money he makes?

Wow.... It makes sense that a neurosurgeon should make more than an FP, but not solely because of intellectual rigor or increased work hours. If that's all that matters, why do used car salesmen make more than PhD researchers? You are so full of yourself that you are not making a rational arguement. I have no illusions of walking in the OR and taking over your job, but what I do is not as easy as you seem to think....

 

[GSresident]

Wow.... It makes sense that a neurosurgeon should make more than an FP, but not solely because of intellectual rigor or increased work hours. If that's all that matters, why do used car salesmen make more than PhD researchers? You are so full of yourself that you are not making a rational arguement. I have no illusions of walking in the OR and taking over your job, but what I do is not as easy as you seem to think....

1) I'm not a neurosurgeon but I respect what it takes to be one. I didn't even come close to working as hard as the neurosurgery residents and I don't have near the brainpower that they seem to have. There is a reason for the popular saying 'it isn't brain surgery.' I have at best average intelligence. There is 1 hamster running around on my wheel but I am cracking the whip on him constantly.
2) If we aren't to judge things by how hard they are to do or how rare the ability is, or how scarce the commodity is, then please propose a system of reward that makes more sense.
3) If I am not making a rational argument then please refute a single point using a rational argument rather than an ad hominem attack.
4) I have never claimed that being an FP is easy, I have merely stated that a neurosurgeon can do the work of an FP but the FP can't do the work of a neurosurgeon.

 

[EdibleEgg]

First off, this is an interesting time politically regarding medicine in the US. Pundits and politicians (as well as lots of people in healthcare) often mention the use of the ER as a safety net for the uninsured. I think the article originally mentioned in this thread was simply saying there's not a lot of evidence supporting common assumptions.

I'm not sure how that was twisted into a discussion about specialist reimbursement. I just looked through the comments again and I don't see anything that implied specialists are making too much money. The only implication was that reimbursements are disproportionate.

GS, your argument seems to be that reimbursement should be a product of how many hours you devote to your residency and how difficult/competitive it is to match. Sure, how hard and smart you work should factor into compensation (although the value of your service to the consumer matters a little, too). However, health care doesn't fit well into the free market (OK, maybe it does in cosmetic plastics, but not so much for the rest of us). So we had to come up with another way to determine reimbursement. You can find lots of different sets of numbers, but the average neurosurgery salaries are approximately 4.2 times average FP salaries. Why not 2.2 times? Why not 42 times? I agree they should be higher, but how much higher?

As for you comment that Neurosurgeons can do the work of FP's, but FP's can't do the work of a Neurosurgeon, I don't agree, nor does it have any bearing on the discussion. Are you seriously saying that Neurosurgery residencies teach you all the skills of an FP residency in all the spare time? We all have our strengths and weaknesses.

 

[BADMD]

During that same year, ~170 neurosurgeons were produce in the US. Yes the talent is that rare. Yes it is that extraordinary to be a neurosurgeon and yes they deserve to be compensated accordingly.

I wish it were really like this, but it isn't. And simply talking about neurosurgeons kind of diverting the point too. What about gastroenterologists? Interventional radiologists?

My speciality produces about 30-40 of people like me every year. Yet, as a cognitive based specialty, I'm lucky if we actually collect more than $60 per patient that our group sees. Most of physicians like me basically do our subspecialty as a "hobby" since, based on the payment rates, we can't make a living as subspecialists. So, sorry, but your rarity = higher payment, falls on deaf ears. I end up doing what I do because I like it and am willing to support myself working in my primary specialty.

In the situation of a pilot, you are talking about a negotiation between the pilots/unions/etc. and the airlines. This is done with the possibility of reaching a compromise agreeable to both sides. It also is implied that one or the other side can say no and walk away. Arbitrarily lowering specialist reimbursement is not the same thing as a negotiation.

No. It is supply and demand. The pilots say they deserve more because it hard to be them. And you are aware that the CMS RVU systems is completely arbitrary as it is.

Furthermore, you have not convinced me that the desire to lower specialist reimbursement is anything other than a move to soothe jealousy and feelings of inadequacy.

Pulls your ego out of your rear end. There are any number of reasons why I chose (yes chose) not to be a surgeon. Individuals with an over inflated sense of self worth was one of them.

Also, keep in mind that most EPs are paid pretty well. Again, if this was all about the money, I could spend all my time working as an EP and make more.

You also have not shown that decreasing specialist reimbursement would do anything about the ER overcrowding.

Increasing the number and availability of primary care definitely would. Even for insured patients, there is a 2 month wait to get in to see a PCP. For the uninsured or underinsured, there are programs to pay for things, but there are no doctors. It gets to the point where seeing a patient that has medicare/medicaid isn't worth it for a PCP. Increasing payment would fix that. The demand is there, but due to an artificial payment ceiling, there is limited supply.

If you want more FP's, the way to do it is not to punish the most capable people for being capable. That is like saying if you want more workhorses you should hamstring all race horses.

You seem focused on neurosurgeons. How about most of internal medicine? Most of the IM docs I've run into are planning to go on to some sort of fellowship. And there are plenty others, that are in other specialties, ophthalmology, ENT, OB/Gyn, GS and others that would be great in the role of PCP. Every needs a good doctor.

What I really find interesting is that you seem to have a remarkable disrespect for doctors that aren't you. Primary care shouldn't be viewed as a lesser specialty than neurosurgery. A great primary care doctor is of far greater value to the world than a great neurosurgeon. Sure, it isn't as cool to get someone's blood pressure below 120/70 and their A1c < 7, but from a morbidity and mortality perspective it is certainly better than a lumbar laminectomy or tumor excision, or any number of other procedures.

One thing you could do to solve the problem would be to stop all of the nonsense of producing physicians who don't really want to work more than 20 hours a week. Why spend the resources producing 3 physicians who will do the work that used to be done by 1? You know exactly what I am talking about and exactly who I am talking about unless your head is buried under 30 feet of self-deluding sand.

PCP does not equal FP. And patients need to have comprehensive medical care before they see there specialist. They need comprehensive care after they see the specialist. We are stuck in this mind "awesomeness" mindset. It is pretty stupid to focus on high tech crazy procedures, then poorly treat the patients' hypertension and diabetes.

I have no idea what you are talking about by physicians who don't want to work more 20 hour week. I suspect you are digging at EPs. I also know that is far from the norm.

Here is the crux of the issue for ER overcrowding:


Making more FP's won't do anything to keep the uninsured out of the ER.

Somewhat false. It also makes it so that the insured can actually see their doctors. Remember the demand exists. The supply is the problem. And if payment is higher, the underinsured have an easier time seeing doctors as well when there is more supply.

It will just mean there are more FP's.

Helping with the supply problem. Also, again, PCP does not equal FP. Internal Medicine is really the work horse of adult primary care.

Cutting the pay of specialists will not do anything for the uninsured because they can't afford specialists anyway. It will just mean that less specialists will accept insurance, which will hurt both the insured and the uninsured.

Again, ignoring the supply and demand. Specialists who refuse to see patients because of they don't like the insurance payment will a) go boutique or b) have to choose something else. I suspect that most will end up accepting lower payments.

But again, this is only about lowering specialist procedural pay because there are finite dollars used to pay for things. Specialists could easily make up for it by returning the diagnostic art of medicine, since the goal would be to increase payment for the E&M codes. Yeah, it isn't as sexy to see and evaluate patients as it is to cut them open, or stick a tube in them, or something similar, but it is the crux of being a doctor.

 

[GSresident]

First off, this is an interesting time politically regarding medicine in the US. Pundits and politicians (as well as lots of people in healthcare) often mention the use of the ER as a safety net for the uninsured. I think the article originally mentioned in this thread was simply saying there's not a lot of evidence supporting common assumptions.

Thank you for weighing in on the subject. The article is saying that if you exclude all of the things that uninsured patients come to the ER for (psychiatric, dental and non-emergent problems). To quote BADMD:

All this paper shows is that there are assumptions about overcrowding made in 53 of 127 papers. That they exclude psychiatric, dental and non-patient care emergency issues seems ludicrous, as those are exactly the patient population that inappropriately utilize the ED. Additionally, just because an assumption is made, doesn't mean it isn't true.

At least he agrees with me on that point.

I'm not sure how that was twisted into a discussion about specialist reimbursement. I just looked through the comments again and I don't see anything that implied specialists are making too much money. The only implication was that reimbursements are disproportionate.

What does 'reimbursements are disproportionate' mean? Again, to quote BADMD:

But again, this is only about lowering specialist procedural pay because there are finite dollars used to pay for things.

He at least is being intellectually honest on that point. You can't argue that 'reimbursements are disproportionate' and 'there is a finite pool of dollars so we need to lower fees for procedures' and not expect me to make the obvious conclusion.

GS, your argument seems to be that reimbursement should be a product of how many hours you devote to your residency and how difficult/competitive it is to match. Sure, how hard and smart you work should factor into compensation (although the value of your service to the consumer matters a little, too). However, health care doesn't fit well into the free market (OK, maybe it does in cosmetic plastics, but not so much for the rest of us). So we had to come up with another way to determine reimbursement. You can find lots of different sets of numbers, but the average neurosurgery salaries are approximately 4.2 times average FP salaries. Why not 2.2 times? Why not 42 times? I agree they should be higher, but how much higher?

If the scarcity of a commodity or the skill needed to provide a service are not a fair way to decide payment for the commodity or service, please propose a system that you think is fair. If you answer that challenge, please include in your answer why it is you think you are qualified to overthrow the laws of supply and demand. Also please address what your concept of 'fair' is.

By the way I agree that health care isn't anything approaching a free market now. Is the solution to the lack of a free market to impose an even more muddled and arbitrary system than what we have now?

As for you comment that Neurosurgeons can do the work of FP's, but FP's can't do the work of a Neurosurgeon, I don't agree, nor does it have any bearing on the discussion. Are you seriously saying that Neurosurgery residencies teach you all the skills of an FP residency in all the spare time?

If a neurosurgeon couldn't manage blood pressure and blood glucose in his sleep, he better not ever have a patient with intracranial hypertension.

We all have our strengths and weaknesses.

I would agree. My weakness is that I sometimes get excited about subjects that I am passionate about. I am particularly passionate when a group of fellow physicians decides to cannibalize me to temporarily fix a broken system. If I have offended you I am sorry.

 

[GSresident]

I wish it were really like this, but it isn't. And simply talking about neurosurgeons kind of diverting the point too. What about gastroenterologists? Interventional radiologists?

I was using neurosurgeons as an example. I chose them because it is an extremely demanding field which requires years and years of training and self sacrifices of the magnitude that can't even be comprehended by the average person walking around. Neurosurgery residents were the ones that I felt sorry for as a general surgery resident working 100-120 hours a week in a hellhole. However bad things were for me, it was worse for them. If you prefer to use another specialty as an example and that specialty fits that mold for you, then please substitute it for the sake of discussion.

Since you mentioned gastroenterology, there are between 2-300 fellowships per year offered with a varying number of applicants. Interventional radiology offered 185 positions in 2008 and filled 99. The match rate for US applicants was 75%. Both of those are relatively scarce specialties and are generally very well compensated.

Compare this to family medicine. If I am reading the data right, the match rate for US seniors into family medicine was 98.1%. Also if I am reading the data right, there were 2636 family medicine spots offered. Internal medicine offered 4858 spots. The match rate for internal medicine was 98%. Please feel free to peruse that data. Its not like I spent 4 hours reading it so I might have gotten something wrong.
http://www.nrmp.org/data/resultsanddata2008.pdf

My speciality produces about 30-40 of people like me every year. Yet, as a cognitive based specialty, I'm lucky if we actually collect more than $60 per patient that our group sees.

Clearly you are a member of a scarce specialty. What is your average waiting time to see you for an appointment?

By the way, is there no cognitive work involved in doing a procedure?

Most of physicians like me basically do our subspecialty as a "hobby" since, based on the payment rates, we can't make a living as subspecialists. So, sorry, but your rarity = higher payment, falls on deaf ears. I end up doing what I do because I like it and am willing to support myself working in my primary specialty.

It ought not fall on deaf ears. I am trying to help a brotha out. If the rarity of a commodity or the skill it takes to provide a service is not the yardstick by which we should measure it, please propose a system which is more fair.

And you are aware that the CMS RVU systems is completely arbitrary as it is.

You should know that as a proponent of an arbitrary system of reimbursement, you should never admit that your system is baseless and arbitrary. The official party line on the RVU system is that it was extremely well studied by the best experts that mankind has to offer. Surely you trust the experts to make good arbitrary decisions for you don't you? Or perhaps you think that your arbitrary system is somehow better than their arbitrary system? Please elaborate.

Pulls your ego out of your rear end. There are any number of reasons why I chose (yes chose) not to be a surgeon. Individuals with an over inflated sense of self worth was one of them.

Ha! I like the thinly veiled ad hominem. No offense taken considering the source. Aren't you the person claiming that it takes no cognitive ability to do brain surgery? Certainly it requires no decision making to fix a ruptured AAA either. Surgeons are idiots.

Increasing the number and availability of primary care definitely would. Even for insured patients, there is a 2 month wait to get in to see a PCP. For the uninsured or underinsured, there are programs to pay for things, but there are no doctors. It gets to the point where seeing a patient that has medicare/medicaid isn't worth it for a PCP. Increasing payment would fix that. The demand is there, but due to an artificial payment ceiling, there is limited supply.

Don't you see that increasing the number of PCP's would thereby increase the supply? What happens to price if supply is higher and demand remains the same? Are we somehow supposed to ignore supply and demand? You will never hear me saying that PCP's are paid to much. I use the same E&M codes that they do and I get paid the exact same amount. I certainly understand that problem. If you want to scrap the RBRVS system and start from fresh with a more market based system then lets rock! Together we can get it done brotha!

What I really find interesting is that you seem to have a remarkable disrespect for doctors that aren't you.

I have the utmost respect for other doctors of every field and specialty. That is why I am not advocating cannibalizing them to temporarily prop up a screwed up system. How can there be any act which is more disrespectful than cannibalism, either literally or figuratively? At least a literal cannibal wouldn't insult me for not wanting to be eaten!!

Primary care shouldn't be viewed as a lesser specialty than neurosurgery. A great primary care doctor is of far greater value to the world than a great neurosurgeon.

By what measure? By who's standards? By what yardstick?

Sure, it isn't as cool to get someone's blood pressure below 120/70 and their A1c < 7, but from a morbidity and mortality perspective it is certainly better than a lumbar laminectomy or tumor excision, or any number of other procedures.

I reckon Ted Kennedy can't be wrong. Isn't he some sort of a leftist hero? I guess neurosurgeons aren't valuable until you need them. You can go to a nurse to get your BP< 120/70 and your A1C<7. Find a nurse to clip your aneurysm.

PCP does not equal FP. And patients need to have comprehensive medical care before they see there specialist. They need comprehensive care after they see the specialist. We are stuck in this mind "awesomeness" mindset. It is pretty stupid to focus on high tech crazy procedures, then poorly treat the patients' hypertension and diabetes.

Most of the world is coming to the conclusion that you don't necessarily need a doctor to manage hypertension and diabetes.

I have no idea what you are talking about by physicians who don't want to work more 20 hour week. I suspect you are digging at EPs. I also know that is far from the norm.

You must not be trying to recruit a partner. About 50% of medical school classes are filled with individuals who would rather be second income earners and raise kids than be doctors. Unfortunately I have numerous friends/family members trying to recruit partners running into that problem.

Somewhat false. It also makes it so that the insured can actually see their doctors. Remember the demand exists. The supply is the problem.

Again, I would never argue that PCP's should be paid less than they are currently getting. As stated above, if the country really wants more PCP's then they should stop training 3 physicians to do the work that 1 used to do.

And if payment is higher, the underinsured have an easier time seeing doctors as well when there is more supply.

So you're arguing that if there are more doctors, they would be more likely to accept no payment for their services? Huh? I'm getting a headache.

Again, ignoring the supply and demand. Specialists who refuse to see patients because of they don't like the insurance payment will a) go boutique or b) have to choose something else. I suspect that most will end up accepting lower payments.

The problem with your solution is that you have to ignore supply and demand to make it work. You have to ignore things like scarcity and skill level in order to make it work. You have to define some arbitrary new system of right and wrong and fair and unfair. Eventually, human nature and the laws of reality will win out. I have no doubt that in the short run, PCP's have more guns and will be able to cannibalize specialists/proceduralists. I have no doubt that the majority of specialists currently in practice are a bunch of cowards. No doubt they will roll over and play nice doggy while the masses of humanity make a feast of their balls. There will be enough specialists to cannibalize to keep the system running for a few years. The problem then becomes, who do you cannibalize next when no one wants to be a gastroenterologist anymore? Who is the next victim when the neurosurgeons say 'to hell with spending 7 years of my life as an indentured servant?' Once you have established that cannibalism is fine and dandy, how will you be able to argue against it when it is your flesh the system wants to consume?