In a recent New York Times op-ed, Rita Redberg MD, a cardiologist and Chief Editor of Archives of Internal Medicine, described the American health system’s penchant for delivering high volumes of “procedures and devices [to] patients who get no benefit and incur risks from them.” The culprit, of course, is fee-for-service reimbursement, used by Medicare, Medicaid and commercial health plans for the past 50 years, which encourages physicians to order more products and services, independent of appropriateness, with few checks and balances.
Dr. Redberg notes the estimate by Medicare’s Chief Actuary that as much as 30 percent of Medicare’s expenditures — up to $150 billion/year, or about 9.4 percent of this year’s US budget deficit of $1.6 trillion — provides no value at all to patients. A 2008 PricewaterCoopers study put the waste estimate at nearly 55 percent of total national health care expenditures, a figure that, in 2011, would translate to almost $1.5 trillion, or just a shade under this year’s deficit.
Much of the health care reform bill is about multi-year pilot programs that will test alternative mechanisms to reduce unnecessary services and costs. And, alas, the politics of change fosters debate that casts aspersions on even the most reasonable of these programs, e.g.,comparative effectiveness research portrayed as death panels. This brings into question whether change is even possible.
So, mindful of the urgency that remains, we offer a modest proposal that can immediately and positively impact care quality and cost. We call this program Physician Fallow, based on proven restorative agricultural practices. Here is how it would work:
- Identify Super-Utilizers. Every American medical community has physicians whose typical utilization patterns exceed the average for their specialty by more than two standard deviations. To identify these super-utilizing physicians, just analyze health plan charge and payment data. In this way, for example, the Wall Street Journal identified a neurosurgeon who in one year performed spinal fusions on 61 Medicare patients, and then an additional 24 fusions on 16 of those patients, giving him one of the nation’s highest rates for these operations.
- Pay Them To Go Away. Physician Fallow would offer the identified doctors a generous stipend not to practice medicine or surgery for several years. In exchange for the promise to do nothing medically related, fallow physicians’ pay could be set generously, say, at 75 percent or even 100 percent of the average of their last three years’ income.
- Poof! Everything Would Improve. The quality, safety and cost benefit from taking these super-utilizer physicians out of commission would be immediate and huge. Millions of patients would avoid unnecessary procedures, escaping risk of serious harm or even death, and saving money for purchasers. Complication rates and hospital deaths would plummet. Physician Fallow would produce better, safer care without health plans telling doctors how to practice medicine. It would simply reduce the number of physicians clearly practicing non-evidence-based medicine and surgery.
- The Multiplier Effect. Here’s the real payoff: Physician Fallow would leverage good care, producing a “cascade” of reductions in unnecessary utilization, not only among fallow physicians, but by also preventing other unnecessary care. For example:
- Cutting unnecessary procedures, like inserting cardiac defibrillators in patients who will not benefit, also reduces the follow-up hospital stays for complications associated with defibrillator malfunction; hospital-borne infections that may result from surgeries to frail, immunologically-compromised patients; and uncomfortable, expensive deaths following multi-organ failure in intensive care units.
- Avoidance of these complications prevents sub-specialty referrals (and costs for medications, procedures, devices, etc.) that would otherwise have been generated.
- This reduces additional complications that would have been associated with the procedures and treatments associated with the last set of referrals.
- And so on…
As a bonus, the Physician Fallow program wouldn’t require changes to Medicare’s fee-for-service reimbursement system. No need to manage complex incentives that impose behavioral changes on all providers. No need to buy costly health information technology systems in every medical setting. (Think of the recent byzantine Notice of Proposed Rule Making (NPRM) for the Accountable Care Organization portion of the Medicare Shared Savings Program.) Instead, Physician Fallow would leave most physicians, outpatient services and hospitals relatively undisturbed, as well as the payment systems established to reimburse them.
Why force everyone to change when a relatively small number of doctors, outpatient services, and hospitals are responsible for the abuses? Instead of trying to reform the whole system, let’s root out the bad apples. The bang for the buck would be large, and we suspect overall reform might become easier afterward.
Fallow physicians could return to practice after the appropriate re-training in quality management, ethics, and teamwork. Some sub-specialists might re-train in a primary care specialty, which would help to redress the shortages there.
Of course, an alternative would be to publicly identify the super-utilizers, exclude them from provider networks when possible, and use other mechanisms to steer patients away from them and toward the high quality performers.
But that could never happen, could it.