Yesterday’s Wall Street Journal opinion page (A17) had a column by Dr. Peter Bach entitled “How Many Doctors Does it Take to Treat a Patient?”. Dr. Bach recently published a study of Medicare patients in the New England Journal of Medicine looking at how many physicians Medicare patients see. The results painted a picture of fragmented, expensive and low-quality care. The average Medicare patient sees seven different doctors in one year, including five different specialists. These aren’t the sickest patients; these are the average. Forty percent of patients have seven or more chronic conduction and see on average 11 different physicians. Does all this care translate to high quality? Sadly, no. Fewer than 30% of people with high blood pressure in another national study had it adequately controlled. Medicare expenditures, ironically, have never been higher, and may reach $500 billion in 2008 in physician services alone. At the same time, reimbursement to physicians for each service has been flat for several years.
What accounts for a system that is increasingly unaffordable, but at the same time makes physicians feel under-valued? How do we explain a system that has provided for exploding utilization of services while quality has not reached expectations? Dr. Bach opines that the problem is the fee-for-service structure of Medicare. He argues that since Medicare pays per service provided it is subsidizing quantity, not quality. Patients are therefore shepherded to as many doctors as possible who deliver as many services as possible, with no incentive to coordinate, unify or improve care.
His prescription: don’t tinker with the system by adding pay-for-performance, the latest policy buzz phrase. He suggests overhauling the payment structure entirely. I agree, though I would add that third-party payment for routine care is another fundamental flaw in the system. When patients don’t pay for their own care prices skyrocket, healthcare is rationed, and quality suffers. My post next week will review a new book that carries this idea further.
Thanks to my friend Justin K. for pointing me to the story.