Home Blog Dear Dr. Berwick

Dear Dr. Berwick

August 2010

I suspect you are a favorite of more than a few special interest groups, now that you control a budget that easily exceeds the GDP of many small countries. Despite this power, no one should envy your position, which is synonymous with “caught between a rock and hard place.” You are charged with controlling spiraling health care costs while avoiding the charge of “Rationer in Chief.”

And you are already dogged by critics who claim you are enamored of socialist ideology because of your proclaimed proclivity for European health care: “I am romantic about the NHS. I love it.” I bet this is one lover you wish you had jilted years ago. Remember, you live in a country that once renamed its favorite form of carb-laden fat, the French fry, the Freedom Fry instead.

I have empathy for your situation, which is why I would like to offer a modest suggestion that assumes you are in this for the long haul. I know that the CMS demonstration projects will eventually prove that bundling payments through an accountable care organization holds the key to controlling costs.

However, implementing this model in our current system will be akin to trying to kill a fly with a jackhammer. There will be a tremendous amount of collateral damage that is not likely to be good for our patients. So we need a transition plan.

The first salvo many years ago was to eliminate the follow-up consult code. This was succeeded this year by eliminating the consult code altogether. Although this did not make doctors happy, I doubt it will go far in controlling costs because it does little to prevent unneeded consults.

Hospitals still suffer from “polyconsultationitis,” the practice of over-utilizing consults for the usual reasons, some more justifiable than others. I won’t go into that now, but obviously I am sensitive to the unfair malpractice climate in which we all practice.

What we need is a graduated plan on the road to bundling that will moderate the current practice of excessive consultation. My idea is to markedly increase pay for the initial consultation, but significantly limit reimbursement for visits thereafter. (While you’re at it, increase pay for the attending of record.) Lest you think I am a consultant hater, let me explain how this is not just a pro-hospitalist agenda.

There are many times when I am attending on a specific condition in which I am doing little more than inadvertently milking the system, rather than providing medical expertise. In these cases, the true management originates solely from the specific subspecialists. I am there to perform much of the paperwork, little more. There may still be some value added for the patient, but at what point does this marginal value added remain cost efficient? Yes, I can admit every stable GI bleeder for gastroenterology, but if they don’t have comorbid conditions, should we both be paid?

On the flip side, I rarely need input from a consultant every day, but I certainly value their initial evaluation. I think they should therefore be paid well for this initial visit, and significantly less for further follow-up. I suspect my hospitalist bias is more than a little apparent because I believe the attending, regardless of medical specialty, should be a competent, involved captain of the ship. This responsibility should not be parceled out to multiple providers as it so often is today.

We’ll need some reasoned exceptions, of course. I know these will be difficult to quantify, but one exemption to decreased reimbursement would include follow-up visits for patients in the ICU. Surgeons also deserve help with comanagement throughout the hospitalization. I readily admit that the policing of this will be difficult and–if history is any example–arbitrary. But I can’t believe it will be any more arbitrary than when bundling becomes the law of the land.

This is the best I can do. If my plan does facilitate a gradual change in hospital culture prior to when the bundling hammer falls on us, it may actually prove to be a useful suggestion. If it just angers doctors and does nothing to improve the efficiency of care, then chalk this up as just one more flawed socialist manifesto.

Anyway, good luck in your new position; you will need it and then some. While I suspect you are not naive about what you’ve agreed to undertake, please remember that not only do we sometimes hate the French in our beloved fries, but we also want you and your ilk to keep your government hands off of our Medicare!