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Physicians often feel helpless due to current payment system realities. It's important to show physicians how they can use the facts to safeguard their futures.
Knowledge is power when it directs action. When someone is presenting a case or clinical research to a physician, both the presenter and the physician understand how the information can help the physician successfully address similar clinical circumstances in the future.
The purpose is the same in presentations of non-clinical information, but the implicit call for physician action is neither universally recognized nor understood. As a consequence, physicians are often left feeling helpless in the face of what is clearly bad news.
Consider some information recently shared during a Grand Rounds presentation to a group of orthopedic surgeons:
• In 2011, healthcare spending in the U.S. amounted to almost 19 percent of GDP. The inescapable conclusion is that we have reached the limit of funds available for healthcare, if we have not surpassed it. Physicians cannot rely upon new money coming into the healthcare system.
• The payment system is opaque, particularly to patients. Most hospitals in a recent survey were either unable or unwilling to hazard even an estimate of the costs for a total hip replacement for a patient with no co morbidities. Other studies have shown that there is no relationship between hospital charges and what they actually get paid for services. Patients surveyed thought physicians' Medicare reimbursement for the surgery was five times what it is, and the patients thought it ought to be about four times the current rate.
• There is a mismatch between supply and demand. The population is aging, and the obesity epidemic puts unsustainable demands on lower extremity joints. Physicians are opting to limit their Medicare participation or retire early, rather than accept prospectively lower levels of reimbursement. Concurrent with a potential shortage of surgeons, hospitals have a lot of unused beds and are continuing to expand their physical plants.
• Physicians have not been effective in preserving their reimbursement rates. Reimbursement levels for hip surgery have declined by as much as 50 percent, in non-inflation adjusted dollars, in the last 30 years. At the same time, hospitals and implant manufacturers have seen their reimbursements more than double.
• The very high volume of total hip replacements performed in the US makes the procedure an obvious target for cost containment and cost reduction.
A lot of knowledge was shared, but it did not indicate a clear path forward. What can and should a physician do with the information?
As in a clinical presentation, the answers were implicit. The difference is that they were not obvious to the audience:
• There will be winners. The current system is unsustainable; and disruptive, systemic change is inevitable. The imperative is either to be one of the people who figures out how to thrive in the new environment, or to align with them.
• Patients are on their doctors' sides. Physicians can leverage that by being more transparent about the reimbursement levels and the problems they present. To be effective, this requires talking actual dollars. "The reimbursements don't cover my costs," sounds like sour grapes. Patients can be moved to contact their representatives in support of physicians, especially if their access to care is a potential casualty of the status quo.
• Given that the pie is not growing, physicians need to get a bigger piece of it. This may be the best news about bundled reimbursements. Hospitals and device manufacturers have done a good job of maintaining healthy margins. Physicians should be able to argue for and achieve a more appropriate piece of the total cost of a procedure for two reasons:
1. The physicians are the ones who are doing the actual work that drives all hospital and implant revenue.
2. Patients tend to choose physicians, as opposed to hospitals or specific devices.
The redistribution will not happen automatically. If physicians are not aggressive and effective in advocating for themselves in the allocation of bundled payments, they will encounter a reprise of the Medicare fee-for-service situation.
The critical question for any presenter is "What do you want me to do with that information?" Each presenter has a duty to provide the answer, either in the course of the presentation or in response to audience questions.