Doctors balk at Senate attempt to cut waste

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The big goal of health care reform is to cut out wasteful spending in order to pay for expanding health insurance coverage.
But some doctors say the way the Senate Finance Committee bill tries to do that would be disastrous.
The bill would require all physicians to participate in Medicare’s Physician Quality Reporting Initiative by 2012 and then, in 2014, use those reports to cut Medicare reimbursement by 5 percent for any doctor whose level of testing and procedures is in the top 10 percent of all doctors in his or her field.
The concept of the bill is good, said Dr. Pete Sallay, managing director of Medicine Sports Medicine in Indianapolis, but the execution is bad.
“I guarantee you, if you try to do this on a national level, it will be disastrous,” said Sallay, an orthopedic surgeon who focuses on shoulder reconstruction. Other physicians around the country also have voiced concerns over the provision.
They worry the government will not be able to collect the data needed to make sure the new law doesn’t punish doctors who do lots of tests and procedures because they see the sickest and poorest patients.
“People aren’t widgets. So you can’t make broad sweeping generalizations,” Sallay said.
The Senate Finance bill calls for the Medicare program to collect health status and demographic data to account for those differences. But in the past, the government has acknowledged that it has been unable to do so adequately.
Health insurers have tried and failed to do the same, noted Stacy Cook, a physician attorney at Barnes & Thornburg LLP in Indianapolis.
“It's just something that's extremely difficult,” she said. “It's something that I don't think has successfully been done.”
A better way to go, Sallay said, would be to change payment models to reward groups of local physicians for reducing costs.
As an example, he noted Clarian Quality Partners. It’s a nascent network of independent physicians signing agreements with the Indianapolis-based Clarian Health hospital system pledging them to work with other Clarian physicians toward improving communication with doctors and overall patient outcomes.
Clarian, which is only one of several hospital systems pursuing this strategy, hopes the network of doctors can then negotiate contracts with insurance plans that would give it bonus payments based on its success at improving quality and reducing costs.
That could include the Medicare insurance plan, if Congress gives it freedom to enter such arrangements. Health reform legislation in the House includes limited pilot programs to allow Medicare to share the savings from improved quality with hospital-doctor groups.
But if Congress instead instructs Medicare to cut payments for overulitization, Sallay says doctors have no faith it will do it right.
“Are you kidding me? No way are we going to trust the government to make a right decision about this,” he said.


  • How do other countries do this?
    I'm not sure where I come down on the current reform proposals, but I'd sure like to hear more about how other countries are dealing with these same issues and, yet, have lower overall healthcare costs AND better outcomes than the USA. There must be solutions in Australia, France, Germany, etc. Bottom-line is we need to come up with a viable reform plan in order to lower our healthcare spending if we want to stay remotely competitive with the other industrialized countries who are spending way less than us. We can't afford not to develop a less-expensive system.
  • Dr. Sallays' Lifestyle
    Joe: Would be very interested in the titles and location of the studies you mentioned about doctors' doing proceedures to support their lifestyles.
  • I don't agree
    Joe, my daughter did have shoulder surgery preceded by an MRI. It was expensive, but effective and less intrusive (thus quicker healing time) and worth every penny of this new technology. If a doc has a tool he can use to provide a better solution, why in the world would you ask him not to use it? Thats really backwards.
  • What he means...
    It is simple. Doctors have tools in order to perform their services. Some doctors require those tools for almost everything they do. A shoulder surgeon is not going to want to determine whether he should perform surgery by physical examination alone.

    It is like telling a gardener that he must quit using his sprinkler so much, but maintain the quality of his produce.

    Also, Dr. Sallay is a specialist who will not get the patients with strains and bruises. He gets the patients with rotator cuff or labral tears. Would YOU want surgery without an MRI to prove what is going on?

    Do you want Ibuprofen and phsycial therapy for a meniscal tear?

    Obama's outlook on treatment is simplistic at best and outright idiotic in reality. Sure, it is CHEAPER, to simply maintain children on Antibiotics for several years in order to treat chronic ear infections. All the while increasing Antibiotic resistance and patient discomfort for SEVERAL years. When an ultimate treatment of the tonsillectomy will completely treat a large number of the cases immediately.

    It also ignores the fact that PATIENT'S have a responsibility for their own care. Putting a diabetic's outcome on the Physician is ridiculous. You can tell the diabetic exactly how to control his blood sugar, exactly how to check his blood sugar, exactly what to avoid eating, and exactly what sort of exercise routine to maintain. It still requires the patient to do it. Maybe we should say that the patient CAN'T have an amputation UNLESS he/she has proven they have done all these things?

    You can't simple swipe a brush at medical care and expect that the ultimate care will be maintained simply by 'cutting costs'. It sounds great... for 'someone else'.
  • what Dr. Sallay means is
    Attacking someone personally is not going to help the debate. Just as Obama accused doctors of performing a tonsillectomy for the bucks instead of treating a child's ear infections with round after round of antibiotics. (Oh, and primary care doctors don't perform tonisllectomies; ENT doctors do). Or cutting off a limb of a diabetic at a charge of $50,000 instead of controlling the diabetes.

    Check out the WSJ article today about healthdcare premiums tripling due to the presently advocated "healthcare reform." Of course, cynics will say this is just an insurance company trying to protect their earnings. By the way, the actual profit margin of insurance companies is something like 2+ percent, number 30 on the profit margin scale. Why doesn't joe attack the lifestyle of Bill Gates or the head of Goldman Sachs?
  • But who is the top?
    To me this is disasterous for the patients, since someone will always been in the top 10% of testing and procedures. Once the first round of reductions are made to the top 10%, these doctors will ratchet back their testing, leaving the next tier of doctors to be the top 10%, who will be punished and retrench, then the next tier of 10%, and so on... until ANYONE who orders a test for ANYTHING will be in the top 10%.

    Whats often left out of these discussions is that chronically sick people are often afflicted with more than one ailment. Heart conditions and high blood pressure, diabetes and circulation issues, I have RA and also chronic pancreatitis. We will spend more time bouncing from specialist to specialist because no one will dare order a test they can't pass off on someone else.

    I am not in support of funding doctor's lifestyles, but I am in support of feeling as well as I can and maintaining the level of care I need to continue that way - just call me selfish, I guess.
  • what Dr. Sallay means is...
    ...that this will be 'disastrous' for his income since he and other surgeons won't be able to get AS rich as they already are if they do too many surgeries...there are many, many studies showing that if a physician CAN justify operating or performing some expensive preocedure then they will, even if there is an equally beneficial and less expensive treatment available! (BTW- I'm sure a 5% reduction in Dr. Sallay's Medicare pay will hardly effect his lifestyle!)

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    1. Socialized medicine works great for white people in Scandanavia. It works well in Costa Rica for a population that is partly white and partly mestizo. I don't really see Obamacare as something aimed against whites. I think that is a Republican canard designed to elicit support from white people for republican candidates who don't care about them any more than democrats care about the non-whites they pander to with their phony maneuvers. But what is different between Costa Rica nd the Scandanavian nations on one hand and the US on the other? SIZE. Maybe the US is just too damn big. Maybe it just needs to be divided into smaller self governing pieces like when the old Holy Roman Empire was dismantled. Maybe we are always trying the same set of solutions for different kinds of people as if we were all the same. Oh-- I know-- that is liberal dogma, that we are all the same. Which is the most idiotic American notion going right back to the propaganda of 1776. All men are different and their differences are myriad and that which is different is not equal. The state which pretends men are all the same is going to force men to be the same. That is what America does here, that is what we do in our stupid overseas wars, that is how we destroy true diversity and true difference, and we are all as different groups of folks, feeling the pains of how capitalism is grinding us down into equally insignificant proletarian microconsumers with no other identity whether we like it or not. And the Marxists had this much right about the War of Independence: it was fundamentally a war of capitalist against feudal systems. America has been about big money since day one and whatever gets in the way is crushed. Health care is just another market and Obamacare, to the extent that it Rationalizes and makes more uniform a market which should actually be really different in nature and delivery from place to place-- well that will serve the interests of the biggest capitalist stakeholders in health care which is not Walmart for Gosh Sakes it is the INSURANCE INDUSTRY. CUI BONO Obamacare? The insurance industry. So republicans drop the delusion pro capitalist scales from your eyes this has almost nothing to do with race or "socialism" it has to do mostly with what the INSURANCE INDUSTRY wants to have happen in order to make their lives and profits easier.

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