A companion blog for The Yale Journal for Humanities in Medicine (http://yjhm.yale.edu)

Tuesday, February 17, 2009

Are Doctors Infected With The Stockholm Syndrome?

Medicare is a great social institution. It saves millions of people from financial destitution.

But many doctors feel unfairly treated by Medicare’s payment schedules. For the past two years Medicare has threatened to cut physician reimbursement by 10% in 2008 and by 20% in 2009. After an outcry from physicians, the cuts were eliminated and physicians were given increases of .5% and 1% respectively. Many physicians were relieved to see that the cuts were reduced and some groups including the AMA actually thanked the Medicare Payment Advisory Committee (MedPAC) for being so understanding.

But rather than thank Medicare for the tiny increases which some consider an insult, it would have been better if medicine’s leadership had preserved physicians’ honor and dignity by rejecting them outright.

This pattern of being threatened then given a small reprieve followed by thanking the oppressors bears great similarity to the so-called Stockholm Syndrome which Webster’s New World College Dictionary defines as a psychological state in which hostages sympathize or even become friendly with their captors.

When threatened by severe price cuts that seriously jeopardize their livelihoods doctors may not be kidnapped or locked in closets but they are hostages none the less. And thanking those who oppress them for being so understanding makes them victims of the Stockholm Syndrome.

Clearly, to go from a 20% cut to a 1% increase represents quite a difference in any physician’s income. But still, groveling before Medicare and thanking it for a puny 1% increase is wrong. This weak showing is sure to encourage private insurers to use the same strategy. By threatening to drop doctors from their lists for failure to conform to their standards for quality and cost-efficiency, private insurers will have another tool to control doctors. This control will become acute once electronic medical records are in place and every treatment, test, and consultation ordered by physicians will become instantaneously available to health insurers to see who conforms to their protocols and who doesn’t.

Far better for the future of medicine if its leadership had rejected Medicare’s 1% increase and dedicated the savings to lowering patients’ premiums.

Ed Volpintesta MD

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My comment:

This is very true!  I think that this was premeditated by Medicare.  They knew physicians would not accept a small increase of 0.5% or 1%, so how do you get the health care industry to accept it?  Threaten a huge decrease in reimbursement and then come back at the 11th hour with the intended puny increase and act like you are doing physicians a favor…Medicare is a “hero”!  It’s crazy, but it has worked for years now.

Physicians are too busy to fight it because they have to see more and more patients to make ends meet.  So, the insurance companies, including Medicare, keep reimbursements low and physicians have to work harder, see more patients in an hour, and focus on documenting the notes to achieve adequate payment.  Now, we are seeing P4P…Pay for Performance…to get any further increases in reimbursement.  Sounds great right?  Is it really an increase?  I don’t think so.  To improve performance, the physician must reduce the number of patients seen and document more performance measures, which means their reimbursements will go down because they are not seeing as many patients as they did.  So, the increase will bring them up a bit IF they can prove that their performance measures are having a positive effect.  Sounds to me like the physician is working differently to receive the same amount of pay.

We are also looking at reimbursement incentives to implement Electronic Medical Records; however, this typically has made the physician slower and decreases the amount of patients that they can see in a day.  How is that effective for the bottom line?  The cost of EMR is extremely expensive.  In my practice of seven physicians, we are looking at over $100,000 to purchase an EMR.  How do we pay for it if we are seeing fewer patients each day?

Unfortunately, the government and insurance companies are developing regulations and policies without input or direct knowledge of how things actually work in a private practice.  In addition, there is no consistency between health plans, so it takes more employees to appeal denials and keep up with all the specific reimbursement policies.

Physicians in private practice are getting the life sucked out of them.  Insurance companies have created patient antagonism toward their physicians.  Society is pointing fingers at the cost of health care and implying that is the fault of the provider of services.  If that is the case, why do physicians make $100,000 to $300,000 a year, while insurance company executives make near a million or considerably more per year?  Why do the insurance premiums continually increase for both the patient and the employer, while the provider of service sees either flat or decreasing reimbursements?  Yet, insurance companies post health profits each quarter.
Charlene  Burgett, M.S.

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