A Doctor's Reflections on Health-Care Reform

Physician payments can't be cut further. Ending frivolous lawsuits is a must.

By Mark Sklar

Dear President Barack Obama and Members of Congress:

I understand that you have undertaken the Herculean task of repairing the health-care system in the United States. As a physician who has practiced medicine for the past 19 years, I think you would benefit from hearing about my experience. I am a board-certified internist with a specialty in endocrinology who currently practices in Washington, D.C. I also provide primary care to many of my patients.

There has been much concern about the rapidly rising cost of health care. I am convinced that costs have increased for a few reasons. First, there are simply more patients in the system. The baby-boom generation has gotten older and now requires care for chronic medical problems. Second, we have unparalleled levels of obesity in our country. This has led to a massive increase in diabetes, hypertension and other chronic problems.

Martin Kozlowski

If we could prevent even a small percentage of people from becoming obese and developing these conditions, the costs of health care could go down far enough to cover everyone's insurance. To that end, we need incentive programs to encourage healthy eating and exercise. Vending machines and fast food should be banned from our schools. Children should be provided with meals that are low in saturated fat, refined carbohydrates, and sugar.

Another major issue is reimbursement. You may find this hard to believe, but when I first started practicing medicine in 1990 I received more payment for an office visit than I am currently receiving. This has occurred despite the increasing cost of practicing medicine, which is the result of rising malpractice premiums, rents, staff salaries, professional membership fees, license fees, and costs needed to comply with various new regulations. What other profession has experienced a reduction in reimbursement over the last 20 years?

I feel strongly that if doctors are reimbursed more for office visits, they will spend more time with patients. This will lead to fewer referrals by primary-care physicians and result in lower health-care expenditures. Currently, harried primary-care physicians don't have the time to delve into medical problems with a hint of complexity. So patients who could be dealt with if more time was available are referred to specialists or expensive radiology studies.

I have heard that physicians may be mandated to participate in a government-run health plan. I sincerely hope that this is not true. First of all, it sounds unconstitutional. As free individuals and citizens of this country, physicians should not be forced to participate in any plan. We have paid for our professional training and worked hard to distinguish ourselves. We owe no debt to the government. If you want physicians to participate in your plan, give them the right incentives and they will flock toward your program.

Electronic medical records have been praised as a way to save money and avoid duplication of tests. It's true that electronic medical records will save some money, but not as much as you probably are counting on. In my practice, if a patient tells us he had a test performed, we call the physician or medical facility to retrieve the results. But a standardized electronic platform will likely be useful for physicians and should lead to better care.

Contrary to what you may have heard, my experience is that smaller practices provide better patient care than larger practices. There are no economies of scale in medicine. If you hire more physicians, you need to hire more support staff to deal with the increased work demands. Larger practices with less support per physician often end up providing worse service. They also require office managers, and sometimes even managers of managers, all of which just bloat costs.

I worked in a university multispecialty practice for seven years before establishing my own private practice. At the university practice, I found that patients' requests often went unfulfilled. Phone messages didn't get to me, and charts and laboratory tests were routinely lost. In my own practice, my fingers are continuously on the pulse of my staff and patients. Because I can overhear how staff interact with patients, I can intervene rapidly if patients are not getting good service. We routinely have patients transferring to us from larger multispecialty practices where they often wait for hours to be seen, aren't called with their test results, and their phone calls are ignored.

The idea that multispecialty practices lead to better referral patterns is erroneous. If I need to refer a patient to a physician in another specialty, I choose the best physician I know to meet that patient's needs. When making the referral, I consider the physician's clinical competence and the potential chemistry between that physician and the patient. I am not constrained by a limited choice of referral options dictated by a multispecialty group.

When I refer a patient, I fax or mail over pertinent notes, lab work and radiology results so that the specialist knows the patient's problem and doesn't need to perform additional unnecessary tests. The specialists that I refer to either call me or write comprehensive consultation letters so that I am aware of their treatment plan and can coordinate future care with them.

I have also heard that Medicare will be looking to recoup money by increasing oversight of fraud. My fear is that fraud will be poorly defined and a simple miscoding of an office visit will be misconstrued as fraud.

The current coding system is extremely complex and requires documentation that physicians often do not have time for. We try to code fairly but our focus is on treating patients, not mentally calculating all the elements necessary to arrive at a billing code under the current system. Even if we attempted to do everything correctly, an auditing contractor could probably find some fault with our coding, thus exposing us to unfair fines and other serious penalties. It is in the auditor's best interest to discover mistakes since it justifies his investigation, and these organizations are paid a percentage of the funds they recoup. This is a blatant conflict of interest that results in the harassment of dedicated physicians.

The government's focus should instead be limited to unscrupulous individuals and companies that are billing for services never rendered. If miscoding is a persistent problem, the algorithms for arriving at billing codes should be changed.

Finally, work needs to be done to correct the malpractice situation in our country. Physicians have been living under the threat of medical malpractice lawsuits for too long. The escalating cost of insurance premiums has driven many physicians out of practice in critical fields like obstetrics and gynecology. And the threat of malpractice litigation leads doctors to order tests that may not be critical to patients' care, resulting in billions of dollars in needless expenditures

Although I am in favor of universal access to health care, I think that we all need to be honest that universal coverage will be a very expensive program. We cannot cut reimbursement to physicians since levels are already too low. And implementing widespread use of electronic medical records and eliminating fraudulent billing will only lead to marginal savings.

I believe that in order to reduce costs, we must give the public incentives for preventing chronic disease, increase the reimbursement for office visits, and implement medical malpractice tort reform. With these changes, I am certain that we can provide more adequate insurance coverage for all.

Dr. Sklar, an endocrinologist in Washington, D.C., is an assistant professor of medicine at Georgetown University Hospital and George Washington University Hospital.