Competing Forces in Medical Care

Dec 01 2011 Published by under Life of a Physician

My November travels took me to the Scientific Sessions for the American Society of Nephrology, a huge gathering of we kidney specialists. As I enjoyed an adult beverage with colleagues from across the country, we began comparing notes about our clinical services. We all hear that we fail to see enough patients!

So how do we determine "enough" for physicians? In private practice you fill your clinics. When the load overwhelms the group, a new doctor can be hired. In academia, where our jobs include teaching, research, and administration, the standard is more difficult to determine. One tactic involves Relative Value Units (RVUs) for physician work.

When you see your doctor, s/he bills a level of service that translates to the amount of reimbursement. That level of service can be translated into the sum of several RVUs for Physician Work, Practice Expense, and Professional Liability. The monetary value of each of these gets adjusted by region, and the final value factor varies over time and by payor. (More on Medicare and RVUs can be found here.) Productivity benchmarks for each specialty are generated annually (Medical Group Management Association, for example, publishes standards). Most academic departments expect a full-time clinician-teacher to generate physician work RVUs at the 75th percentile. Roughly one-quarter of a physician's time will be taken up with trainees. The percentile can be adjusted by job expectations in other ways. Someone with 75% of their time protected for research should only be expected to generate one-quarter of the 75th percentile under this model.

So the bean-counters in our departments look at our numbers and tell us we aren't meeting national standards, but none of us know who they are auditing to determine these numbers! Unlike in adults, pediatric kidney disease has a relatively stable prevalence in the population. Many of us exist in sections that provide the only service in our specialty for a state or multi-state region, so we do not have competition from whom to "steal" patients.

So where do we get these additional patients?

Some centers develop new services. Kidney doctors run blood through filters all the time. Buy a machine with a different filter and we can do plasmapheresis. Of course, that means someone else in our center no longer does those patients; this approach is often a zero-sum game. No, the answer much of the time would be to see patients we might otherwise not see.

For example, asymptomatic microscopic hematuria (blood in the urine not visible to the naked eye) is a common pediatric problem. The typical work-up involves a number of tests. If normal, we just watch blood, urine, and blood pressure over time. Primary care physicians could handle this condition with phone support from us. At this time, our inclination is to see all patients referred to us, rather than doing this level of triage for which we receive no RVUs and no payment.

We have two competing forces here. One involves running our clinics like a business, with carrots and sticks for meeting productivity standards and bringing in the bucks. However, this occurs at a time when there should be even more pressure to avoid unnecessary visits to specialists to keep everyone's costs down - but there is no financial incentive for that.

I do not have an answer. Clearly, current capitalist forces are not going to fix our "system."


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