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Touring a medical center: No margin, no mission

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Go on a tour of a “midsized academic health center” with Dan Shapiro, chair of the Department of Humanities at Penn State College of Medicine, by reading his essay in the current issue of Health Affairs. Excerpt:

“It doesn’t make sense to me that we live and die by our procedure-based departments. Lifestyle is implicated in many if not most diseases, from diabetes to heart disease and some cancers, but the experts in helping patients change their behavior–our primary care and behavioral scientists–are poorly compensated. It is, in short, depressing.

We do stomach stapling, but won’t invest in teaching young, mildly overweight patients how to eat inexpensive, healthier food that can still taste good or how to distinguish anxiety from hunger. We’ll reimburse cardiac surgeons for numerous invasive interventions, but, aside from a few demonstration projects, we won’t reward doctors who successfully get their patients to lose weight. We pay physicians to do complex procedures, but then we don’t follow up to make sure our patients have even picked up their medications.

Are we reimbursing procedures better because they take more skill? Is it truly harder to install a titanium hip joint than to help patients drop pounds or consistently do weight-bearing exercise? Is it harder to blow open an artery than to help a person quit smoking? I respect the skills of my surgical and procedural colleagues, as well as all of the specialists who walk our halls. But I also know it’s incredibly hard to help kids identify and avoid what triggers their asthma, and I know that it takes special skill even if it looks like “just talking.”

Perhaps it’s because we think procedures are riskier, and physicians who do procedures should be rewarded for their courage. But is overcoming risk in the quiet of the operating theaters truly more courageous than working in an asthma clinic, helping a flood of patients with limited resources navigate the challenging waters of a life-threatening breathing disorder?”

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Roy M. Poses MD

April 7, 2010 at 12:57 pm

It was a really nice article, but really begged the question about why we pay so much more for procedures than for thinking.
At one level, why procedures are more lucrative than thinking is not mysterious. The system Medicare uses to determine what it pays has been subject to regulatory capture. It is effectively run by proceduralists, and by their sub-specialty societies (which in turn are mainly funded by the companies that make the devices and drugs used in procedures). And most health insurers follow Medicare’s lead in how they pay physicians.
How this came to be, and why there is so little discussion of it, are more mysterious.
We have discussed this on the Health Care Renewal blog. I suggest reading these posts in order, but detouring to the links and citations in each.
http://hcrenewal.blogspot.com/2007/03/on-disparities-between-reimbursement-of.html
http://hcrenewal.blogspot.com/2008/07/can-we-fix-medicare-while-pretending.html
http://hcrenewal.blogspot.com/2009/02/what-ruc-again-one-of-worlds-most.html
http://hcrenewal.blogspot.com/2009/06/letter-from-ruc-and-my-reply.html

Daniel S. Goldberg

April 8, 2010 at 10:02 am

Roy,
Re:
“How this came to be, and why there is so little discussion of it, are more mysterious.”
There are some people working on this. (For one, me!). But it is complex and is inordinately tied up in the history of medicine itself in the U.S., insofar as the 19th century featured a change from a humoral medical cosmology to one which focused on the discrete objects of disease. It is no coincidence that the stature of proceduralists like surgeons began to rise dramatically during this time.
(Note that I am certainly not bemoaning the dialectic move away from humoralism, although there is excellent evidence it still exerts a much larger effect in clinical practice, research, and in Western cultural tropes regarding health and illness than many believe [the bizarre persistence of the chemical imbalance theory of depression being a nice example]. I am rather suggesting that the move from humoralism, which required investment in the subjective life of the patient, to allopathic medicine, which emphasized objectification and material pathologies, has had some unfortunate and less-discussed consequences, in addition to its obviously salutary ones).
Feel free to email me if you’d be interested in continuing this discussion.