OK, I'm going out on a limb. As I watched Bernanke on Bloomberg this evening, I heard him say something about being alert to areas in which excessive risk assumption is not being adequately compensated.
Hmm, sounds like primary care, I thought.
A few disclosures and acknowledgments; I am not an economist, taking a class in a public health school just doesn't cut it. I've played with the markets for years and have a passing familiarity with concepts related to valuation and one of the reasons I am more comfortable in the US than Canada. Markets work better at determining value than governments do.
So if a provider of a service can be somehow valued in terms of the assumption of risk, most primary care physicians work in a generally low-risk environment. Every service provided by a procedural specialist may represent a greater absolute reduction in risk. But risk is also additive, so the total amount of risk assumed by a primary care physician could be greater if considering the proportion of the population that requires the service.
One of the reasons that primary care physicians are generally paid so much less than procedural specialists is the shortness of supply for those skills. In a consumerist society, we seek rare and unusual skills and pay a premium. The perception of risk can be influenced by so many factors that cannot be scientifically objectified.
Maybe the market for various specialties is working as intended, but primary care is not using its leverage. Using leverage on referrals and denying approvals for emergencies that did not go through primary care may seem as repugnant to others as it does to me, but it is merely the most obvious level of leverage we have. It's what the insurance companies expect of us, because we are the primary risk reduction tool for them.
Maybe structural incentives need to be realigned so that we are expected to respond to the patient's perception of risk and not the perception of other stakeholders.
Maybe I just need to go back for a PhD.
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2 comments:
I think you are confusing our current compensation system with a market.
I cite the recent survey made public by Merrit Hawkins that the demand for FP's is at an all time high but compensation offers have only gone up modestly. I can send the report if you can't find it online.
Physician compensation is driven by medicare RVU rates. Thus, we are in a monopoly- state controlled economy, by in large. Some docs opt out and do the cash/ mini practice thing, which IS becoming more popular. But I do not believe the "risk" you are referring to has any effect whatsoever on compensation other than it is one of the factors that HCFA considers in setting RVU rates.
You talk about leverage in referrals. That was the HMO? Managed care debacle. The reason that failed( FP= gatekeeper) was because we were going in two directions at once.
1. Authoritative limits on access( gatekeeper) without a mandate, See recent article in Health(on line mag) telling Pt's how to lie to get the test they want from their doc...
2. Service to a public that expects to be treated like a customer.
Docs had to struggle with two masters, and the family doc was right in the middle.
Unfortunately there is not real sense of purpose, direction for primary care. We haven't really determined who we are, what we offer, what we are to be providing as a "family doc".
Sorry for the rant.
Your rant is more than welcome. I share many of your frustrations.
Physicians do not always have the sense of insurance companies (which I criticize for other reasons). If they can't make a decent profit in a market, they withdraw. If family docs don't make a decent living, what do they do? We complain... and complain... and complain...
Our behavior has encouraged not being paid appropriately for the risk we bear. Granted there are distortions because of the perception of risk... HCFA does not value what we have to offer and values it differently than we do.
Slowly family physicians are withdrawing from Medicare and Medicaid. To the extent that the balance between supply and demand for our services are going to change.
Nobody has to accept a given compensation offer. My weakness (like most doctors) is negotiating. Make 'em hurt (but do so within the ethics of the profession) and reimbursement will change.
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