Providers and their “boy who cried wolf” problem

Remember that useful physician audit study that imploded last month? Maybe providers are wishing they hadn’t helped to kill it.

Remember that useful physician audit study that imploded last month? Maybe providers are wishing they hadn’t helped to kill it.

This week’s debt ceiling agreement includes some Medicare cuts. The Obama administration reassures the public that these cuts would only affect providers. Not surprisingly, many providers are unhappy. They suggest that reduced reimbursements will damage primary care or will reduce patient access to care. They might have a good point. They might also be ignored, because providers have a well-deserved “boy who cried wolf” problem. They deploy the same objections every time, whether changes in reimbursement are reasonable or not.

Wouldn’t it be great if providers could cite some credible unbiased studies to document how reduced reimbursement might reduce patients’ access to care? Oh yeah. There was such a study. Physicians helped to kill it.

In case you forgot…. About a month ago, the New York Times included a story with the scary headline “U.S. plans stealth survey on access to doctors.” As Pear described, the National Opinion Research Center here at the University of Chicago had signed a $347,000 contract with the Department of Health and Human Services to conduct audit studies of more than 4,000 doctors in nine states.

Paralleling the methodology of a recent New England Journal of Medicine study, NORC auditors would have called each medical practice twice to request appointments. Callers would follow an explicit script. In one of the calls, auditors would have reported that they have public insurance such as Medicaid. In the other call, auditors would have reported having private coverage. Some physicians would have also received a third call for an identified survey researcher, who would inquire about whether these providers accept different types of insurance.

By and large, medical providers hated this study.

“I don’t like the idea of the government snooping,” said Dr. Raymond Scalettar, an internist in Washington. “It’s a pernicious practice — Big Brother tactics, which should be opposed.” …

Dr. Stephen C. Albrecht, a family doctor in Olympia, Wash., said: “If federal officials are worried about access to care, they could help us. They don’t have to spy on us.”

Utah Senator Orrin Hatch criticized the study as “wasting taxpayer dollars to snoop into the care physicians are providing to their patients.”

Two days later, the White House placed the proposed study on “indefinite hold.” Official Washington quickly moved on.

From a political perspective, I understood why the administration pulled the plug. The big-brother optics were obvious. Physicians were not happy, in part because the profession would have been embarrassed by the likely findings: That many doctors avoid low-income patients with public insurance. The administration could ill-afford to irritate a medical profession with whom it is negotiating many issues in health reform.

On the merits, this study was quite sensible. The federal government spends some $800 billion every year for medical care. We should spend 0.00004 percent of this princely sum to learn what we are actually buying (or trying to buy) with this massive sum. Providers should show greater support for such efforts.

Right now, we are blinder than we need to be as we contemplate painful measures. Ironically enough, providers themselves have less help than they might in getting past their “boy who cried wolf” problem.

Author: Harold Pollack

Harold Pollack is Helen Ross Professor of Social Service Administration at the University of Chicago. He has served on three expert committees of the National Academies of Science. His recent research appears in such journals as Addiction, Journal of the American Medical Association, and American Journal of Public Health. He writes regularly on HIV prevention, crime and drug policy, health reform, and disability policy for American Prospect, tnr.com, and other news outlets. His essay, "Lessons from an Emergency Room Nightmare" was selected for the collection The Best American Medical Writing, 2009. He recently participated, with zero critical acclaim, in the University of Chicago's annual Latke-Hamentaschen debate.

9 thoughts on “Providers and their “boy who cried wolf” problem”

  1. They also have a long standing head-in-the-sand problem. In the 60’s my physician father – a Republican – was on a peer review committee to help establish standards the government could use for Medicare and Medicaid. He traveled around our state encouraging doctors to participate in this process but all he heard was that they didn’t want the government involved, socialized medicine, etc. Over and over he tried to convince them that standards would be set no matter what and that it would be better for them to have a say rather than allowing a bunch of bureaucrats to do it. He wasn’t crazy about the idea of government regulation but he was a realist who could read the handwriting on the wall.

    Towards the end of this life he said that it was ironic that all those doctors who worshipped the private sector and had fought so hard against government involvement were now freaking out because they were being dictated to by for-profit insurance companies. What they had not thought about was that as citizens they have much more power to influence the government than they could ever have with insurance companies who see them as mere cogs in the machine.

  2. Isn’t there a fallacy of composition problem here? As with removing the end-of-life counseling provisions from the PPACA, a few especially loud political actors can have a disproportionate effect, likely counter to the interests and even stated preferences of the majority of physicians affected by this change.

  3. > From a political perspective, I understood why the administration
    > pulled the plug. The big-brother optics were obvious. Physicians
    > were not happy, in part because the profession would have been
    > embarrassed by the likely findings: That many doctors avoid
    > low-income patients with public insurance.

    A few years ago when I had a job with a mid-grade employer-provided health plan I ended up sitting in my (then) primary care doctor’s waiting room for several hours 2-3 times week for a number of weeks. Over time I did some basic input/output calculations, looked up some numbers, etc, because it appeared on the surface that there was no way she and her partners could be paying themselves any reasonable salary while maintaining the business of the practice. And my basic business arithmetic showed that unless there was some other source of money coming in (perhaps kickbacks from an associated lab or referral group? but I thought that was not allowed) there _was_ no way they could be repaying themselves for 7 years of school, loans, etc. And that was even at the rate my private insurer was paying; it was a mixed neighborhood and they clearly did take Medicare, Medicaid, and pro bono cases as well.

    Sure enough, within 3 years my doctor and all her partners had left for academic jobs, military positions, etc. In fact _every_ good primary care doctor I have had in the last 15 years has eventually quit direct practice for a position with some sort of benefits, fixed hours, and non-billing income. (I don’t live in California; I suspect there some of them would have gone to Kaiser)

    There are a lot of problems with the US’ current system of providing health care. I just don’t see overbilling or excessive charges by primary care providers as one of them. And while I like to tell myself I would do the “right thing” in that situation I certainly understand the economics that drives physicians with loans, families, and low-in-the-pecking order reimbursement rates to try to minimize the number of patients who do not have decent private insurance plans.

    Cranky

  4. Cranky – I don’t think the point of the cancelled research was to demonize primary care providers. It was – I thought – part of an effort to get evidence for improving a system that is going to be slammed by a very large jump in patient numbers once the PPACA is fully implemented. (Of course, if the GOP sweeps in 2012, that day will probably never arrive.)

  5. Cranky — what does that tell you about the doctors and medical groups who thrive in the current environment? Many of the reforms currently proposed are along the lines of saving money by increasing reimbursement to primary providers, especially for visits that don’t have billable procedures associated with them (you know, the ones where the doc actually talks to the patient, reviews the file and thinks about what to do next) and for phone consultations (which are generally not reimbursed at all under the current system). It is perhaps indicative that in vermont a survey of physicians’ attitudes toward single-payer (albeit not well designed or executed) showed overwhelming approval among primary physicians and overwhelming disapproval among specialists.

  6. > Paul 8:57

    That sounds great. It is what I would like to see happen. The problem is that – much as with education “reform” – once efforts of this nature get rolling they never work out that way. Very similar to what happens when a manufacturing corporation retains Bain Consulting to “improve processes” and “save jobs”: the end result is always that the jobs get shipped to China.

    Cranky

  7. In the 1980s, I did consulting for large specialty doctors groups. I got so sick of the whining and crying over Medicare that I actually dug into the literature on physicians’ incomes.

    When did the largest jump in doctors’ incomes in history occur? Right after the Medicare Act was first established.

    Also, a study in a respected journal of Radiology made a survey of their members and then commissioned a small study to research why people went into that specialty. The number one reason that emerged was the income.

    Now, I don’t want a B,C, D or F student to be reading my xrays after a major car accident and I realize that intelligent people can be motivated to public good by sheer damned greed, but I feel that financing a medical education for anyone who wants one would be a great step to breaking the guilds’ control of medicine.

    There was no such profession as “medicine” before the First World War. It was not until logical, sequential studies were made and assessments of what worked in the militaries and what didn’t, that medicine stopped being a fraud and started being a professional group. The recording process and evaluations of individual “doctors” weeded out a lot of quacks from treating or operating on soldiers. When those ideas were embraced by the military regulations, they started the profession of medicine.

    It was not doctors that professionalized medicine, it was the great generals that got so many soldiers slaughtered through sheer unprofessional ignorance. Ironic, eh?

  8. Things That Are Useless,
    Again I can’t disagree, but have you seen any proposals on heath care reform, budgets, Medicare, etc. that even touch on the idea of reforming medical school admissions and tracking, and “valorizing” (as Matt Yglesias would say) primary care of extreme specialties? I haven’t; it is mostly tinkering around the edges and punishment of the guilty.

    Cranky

  9. When looking at a program like Medicare or Medicaid, there are only four real ways to reduce costs.

    First, you can change eligibility. Making fewer people eligible would reduce costs. In the case of Medicare, this would be an age-change, for the most part (some long-term care eligibility, etc. would be in play as well). In Medicaid, you find that different states that have different standards of eligibility (although the feds set a floor), usually based upon the Federal Poverty Line. Some states are more generous than others. However, politically, it is very difficult to reduce eligibility. Once you’ve established a baseline, going backwards is really unpopular (although it does happen).

    Second, you can change the range of services covered. Dropping dental and eye care is a frequent approach by states(Medicaid), but regardless of how you do it, cutting back the type of services that are covered by either program reduces their costs overall. Again, this is difficult to accomplish politically. There is lots of screaming about denying people coverage. Plus, there isn’t a great deal of “slack” in what is covered to begin with.

    Third, you can push to make the programs more efficient. This is usually cited as “cutting waste” or “getting rid of fraud and abuse.” The problem with this method is that Medicaid and Medicare are already extremely efficient. They operate with a low overhead, despite the popular perception of an inefficient federal government. As far as fraud and abuse, they DO occur, but hardly at levels that would make a dent in the general operating budget. You’re looking at rounding errors, not serious coin.

    And lastly, you can cut payments for providers. This is the easiest way to go about it, politically speaking. Sure, providers scream, but most people don’t know what the government pays for the services that hospitals and doctors provide to them. Ask someone on Medicaid or Medicare how much it costs for an office visit, and they’ll tell you what their co-pay is. Most people don’t know the actual cost, or how their provider gets reimbursed. And while providers might yell, as a politician, you can truthfully claim that you haven’t cut benefits or range of services. However, it does mean that some doctors refuse to take patients covered by Medicare or Medicaid.

    I’ll bet that audit would have found that physicians are reluctant to take Medicaid and Medicare patients. That says one thing. But it doesn’t mean that they necessarily “cried wolf.” Making cuts in payments to providers isn’t likely to make them more likely to accept these patients; it makes them less likely to do so. And they aren’t required to do it. Hospitals are required to take any patient in life-threatening need. But that doesn’t apply to most physicians, it doesn’t apply to services such as dialysis, and it’s a real problem.

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