Reader's and Author's Responses to When Medical Care Is Financially Conflicted

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Reader's and Author's Responses to "When Medical Care Is Financially Conflicted"

Posted 08/03/2007

Hymin Zucker, MD; R. Klepper, PhDAuthor Information

To the Editor,

I could not agree more with Klepper in his piece on financial conflicts in medicine.[1] It is my belief that even the most moral and honest physicians will transform after years of honest practice as long as the only real way to advance financially is to stretch the boundary of what is right for the patient.

I have seen it since my emergence into private practice when I was instructed to include chest x-rays, electrocardiograms, and pulmonary function tests on all patients who received a physical. More recently, I find that when contracting a specialist such as an orthopedist, I must also contract his imaging service so he can deliver the best care possible. That all sounds well until I find out his CT scanner is old and my radiology consultants report "issues" with the scans. Moreover, even when the primary care physician (PCP) obtains the appropriate imaging, the orthopedist feels obligated to rescan. This occurs in the cardiologist's office with nuclear scans and echoes, in the gastrointestinal setting with capsular imaging over endoscopy, and in the neurology setting with electromyography.

Wouldn't it be nice to have someone orchestrate the delivery of healthcare, in a manner that ensured resolution of illness, to assure that all subsequent care would have to fit into an "of benefit" category or not, and if not of benefit then that someone would be obligated to provide feedback to the consultant in real time, which would put everyone on the same page in terms of the patient's care plan?

Of course, this someone would need to be considered a legitimate player in the healthcare reform process, and proper payment for services should result. I guess what I always come back to is the Advanced Medical Home concept that is beginning to get exposure. It is up to the PCPs to embrace this and reinvent themselves. Once achieved, they will have an avenue through which to legitimately demand higher reimbursements through control of the majority of patients that will demand quality, unbiased care.

Hymin Zucker, MDWest Palm Beach, Floridahzucker@...

Reference

Klepper B. When Medical Care Is Financially Conflicted. MedGenMed. 2007;9(2):39. Available at: http://www.medscape.com/viewarticle/556213. Accessed May 30, 2007.

Reply from Author:

Dr. Zucker is right, of course. The Advanced Medical Home model is correct in concept. But at this point, few PCPs possess the infrastructure required to support that level of care coordination. Most lack the time to do much downstream management. Nor do they have access to objective data on specialist quality and cost to know who will do best by their patients.

Medicine's high fragmentation remains the major obstacle to this kind of integrated patient management. Most medical practices are small, undercapitalized, and relatively isolated from other practices, at least in terms of the information required for true team-based approaches.

That said, it seems fairly certain that several different market vectors are converging and that larger practices that lend themselves more easily to comprehensive patient management will organically emerge in the next several years. Three trends will drive the rapid expansion of physician groups.

The first is the declining financial feasibility of small practice. This is particularly true for primary care, but specialists are seeing their incomes drop as well, and this will only get worse as the healthcare crisis continues to deepen.

The second is the growing sophistication and affordability of comprehensive practice management IT systems. These will include electronic medical records with continuously updated embedded evidence-based best practice guidelines as well as a variety of useful artificial intelligence decision support functions. We're now seeing comprehensive systems available for about $6000 per physician per year, a dramatic difference from even a few years ago. These systems will continue to become better and cheaper and will facilitate the seamless integration of very large multisite, multispecialty practices. Indeed, one of the advantages of the larger practices is that they'll achieve the economies of scale required to easily afford enterprise-wide implementation of these tools.

Third is the inevitability of performance-based reimbursement. Medicare and virtually every payer now understands that fee-for-service care encourages more care, rather than the right care, and is refining the metrics and incentives that can work best within each specialty and service. As a practical matter, hitting the targets required to access the top financial incentives would almost certainly require the new information tools, deployed in ways that reflect integrated patient management across specialties.

In other words, like it or not, market forces appear to be driving medicine into a more corporate era that will demand greater adherence to best practice guidelines, more integrated patient management, and more clinical/financial performance transparency. While the independence that has characterized the last several decades of American medicine will probably disappear for all but a few physicians, the care delivered should be more holistic and team-based, less financially conflicted, and more cost effective. It should be better for patients and better for whoever is paying the bill. And from what I can tell of current physician morale, it should be a more satisfying work environment for most doctors.

R. Klepper, PhDThe Center for Practical Health ReformAtlantic Beach, Floridabklepper@...

http://www.medscape.com/viewarticle/560270?src=mp

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When Medical Care Is Financially Conflicted

Posted 05/18/2007

Klepper, PhDAuthor Information

The Cleveland Plain Dealer recently ran an article[1] about a prominent physician who held a financial stake in a spinal procedure that he and his well-known clinic promoted. The procedure was more costly and surgically complex than another more proven approach for the same condition.

Ironically, the doctor sat on the clinic's Conflict of Interest Committee, and on its Board of Governors that last year ousted a cardiologist for failing to disclose stent royalties.

Financially conflicted care is not new or isolated.[2,3] We know that many doctors routinely increase income by delivering unnecessary or suboptimal services. But this article raised important questions about financial temptation, and about the dissonance between some physicians' self-images and actual behaviors.

Physicians have a sacred trust with patients. I believe most doctors see themselves as mission-driven and believe their decisions follow scientifically objective criteria.

Patients also see their doctors these ways. So when physicians' decisions are not objective, when they accrue at patients' expense to the physicians' financial benefit, patients are betrayed.

A profession succeeds by adhering to standards that protect the interests of the professionals and their charges. When care is conflicted without repercussions, when standards are jettisoned and individual interests take precedence, hasn't it become unprofessional?

Medical profiteering steers care away from what's best for the patient in favor of what's best for the doctor. That greed undermines the entire process: It compromises quality, increases cost, and erodes the patient-physician relationship.

Like all of us, physicians are susceptible to the financial conflicts that are inevitable in an entrepreneurial society. Clearly, professional self-regulation isn't working. Nor is the system yet transparent enough to discourage these behaviors and protect patients. So additional safeguards are required. Physicians must self-correct before an external force does it for them.

That's my opinion. I'm Dr. Klepper, President for the Center for Practical Health Reform.

http://www.medscape.com/viewarticle/556213