If you are in a concierge medical practice or you are a specialist, you can stop reading.  But, if you aren't and are concerned about the pressure to reduce the costs of care while not compromising accessibility or the quality of care, then understand the incentives matter critically to you; ignore that and you will pay dearly.

Perhaps you feel how the insurers pay you is what it is and you'll deal with it.  You thought you were done with managed care, but you are still being manipulated, making less while the specialists aren't so affected.  You see your patients are getting hit with ever higher out of pocket costs (cost-sharing).  You cannot stand the costs of dealing with third party bureaucracies, their automated telephone attendants, the ridiculous prior authorization procedures and other forms of having to 'jump through hoops' for your patients. You didn't go to medical school to learn how to negotiate for the meds your patients need, or a nebulizer, assist device, home or mental health care or a test. Is anyone paying for your advocacy or caring?    I thought not!

I am speaking as a former medical director who got into plenty of trouble for advocating for physicians.  (How I lasted over 30 years is beyond me.)

·           Whenever I bring up the idea that incentive realignment is fundamental to health care reform, I get the feeling my audience is under whelmed, but any medical manager will tell you, 'Pay a doc by visit or procedure and they will generate visits and procedures. Dr. Caldwell B. Esselstyne (Claverack, NY, circa 1965) put it aptly: "Fee for service medicine is practiced on a piece-work basis; the incentive in piecework is to generate pieces." Clearly, 'physician-induced demand' can help the revenue stream, but consider—are those ears rechecks really necessary? How about that PSA test?

·           Similarly, putting practitioners at risk for the cost of an 'episode of care' while insulating them from the cost of referrals or hospital admissions is a perfect way to foster referrals and admissions. This may or may not be 'dumping,' depending upon the integrity of the 'medical home." Paying them by the hour is no panacea, either--it puts a lid on productivity. I could go on (I was in the trenches as a medical director for over 30 years), but the reality is there's waste and duplication in medicine and the physician's pen or electronic health record (EHR) explains most of these expenditures.

Ref: "Re-aligning Incentives to Enhance Value: Can We Manage the Medical Arms Race?" MTLF.org presentation 10/14-15/07 Minneapolis, MN [1/5/13 link failed].

This is not to say that health care isn't an important part of the economy; it's just that it could be more efficient. Consider that about $7 billion of wasteful spending in American health care breaks down as follows:

$116.3 million: Prescribing antibiotics to children with sore throats caused by a virus.

$5.8 billion: Prescribing a brand-name cholesterol-lowering drug without trying a less expensive generic medication first.

$527.4 million: Bone density scans for women ages 40 to 64 years.

$175.4 million: Ordering CT Scans or MRI’s for lower back pain.

$47 million: Pap tests for patients younger than 21 years of age.

"Top 5 Unnecessary Health-Care Costs" (WSJ Health Blog) with reference to an October 1, 2011 Archives of Internal Medicine article, "'Top 5' Lists Top $5 Billion."

What does this have to do with debit cards? The Federal Reserve intends to limit the interchange fees banks charge stores each time a debit card is used for a purchase, but the banks contend they should charge for debit cards because “'If you’re a restaurant and you can’t charge for the soda, you’re going to charge more for the burger.'” The banks seem to ignore the fact that they are saving a lot of money by eliminating checks. Their "simplistic statements are merely an attempt to rationalize and obfuscate one of the largest illegal transfers of wealth from consumers to banks in American history."

"Charging for Debit Cards Is Robbery." NY Times Oct. 6, 2011

In similar fashion, when doctors manipulate the system, they are responding to economic pressures and they are biased, thinking they will be getting what they deserve, outwitting the insurers and regulators, as it were. But, remember the old balloon analogy—squeeze it in one place and it pops out another. I say, Doctors, who are you kidding?

My message and recommendation is simple—document and justify well.  Be proactive.  Give a reasonable diagnosis or argument that will support a request for a special med, referral or test.  Think like the insurer; they certainly won't think like you.