Unintended Consequences

BY FRANK J. VEITH, M.D.

Health care costs are exploding--a major national problem threatening our economy, the viability of certain industries, and even solvency of some small businesses. These costs are likely to continue to rise as new technology is introduced, wider health insurance coverage is recognized as a political imperative, and rationing of health care remains unacceptable.

It is not surprising, therefore, that third-party health care payers, including the federal and state governments that fund Medicare and Medicaid, have found various methods to diminish payments to "these rich doctors" who provide medical and surgical services. It is of little consequence that these payments make up a very small fraction of overall health care costs and that these doctors spend many expensive years in training; that they are required to work long hours, and need to be responsible for care nights, weekends, and holidays. Physician, and particularly surgeon, reimbursement is vulnerable and has not only failed to keep pace with inflation but also has decreased in absolute terms over the past 2 decades. One of my colleagues, a prestigious senior vascular surgeon who is working as hard as ever, noted that between 1990 and the present his income in unadjusted dollars declined to 25% of what it had been.

This may be acceptable to the public and their legislators, who perceive physicians and surgeons as well compensated to begin with, and who are really not very concerned about rapidly escalating malpractice insurance premiums and other rising practice costs. As long as people continue to get their health care without concern for access and don't have to pay any more for it, why should the public and their governments care if doctors are paid less?

They should care a lot and should recognize the unintended consequences of reducing doctor compensation. When anyone's income is reduced, the natural tendency is to adopt behavior to offset the reduction in some way. This might mean getting another job--out of the question for doctors who are already fully engaged in their profession and are "one-trick ponies" with a unique and nongeneralizable set of skills. Or it might mean working harder at their original job. Because the basis of physicians' pay is the number of patient visits, working harder means seeing more patients. This means spending less time with each patient and requires that the physician be less thorough and less careful. The quality of care has to be diminished--clearly a bad thing for patients.

Surgeons get paid on the basis of the number of procedures they perform, and they are prohibited by law from charging more per procedure (with the possible exception of some cosmetic practices).

Thus, for surgeons to compensate for diminished reimbursement, they must perform more procedures. To do that they must take less time per procedure. This will not only produce a probable decrease in quality, but will also run the risk that surgeons will perform some unnecessary procedures. Moreover, to save time in which to do additional cases, they will tend to shy away from the more difficult, time–consuming cases that really need to be done, and opt instead to do the quicker, easier cases for which the indications may be less compelling. Clearly all these unintended consequences are bad for patients.

Although these unintended consequences can occur in most specialties, let us consider some specific ramifications in vascular surgery. Vascular surgeons are poorly compensated for performing leg bypass operations for critical ischemia, procedures that are usually difficult and time–consuming. In contrast, reimbursement for endovenous vein ablation, a relatively simple and quick procedure, remains excellent. Small wonder that vascular surgeons and vascular radiologists (as well as other nonvascular specialists) are making the treatment of venous disease a larger part of their practices. The unintended consequence is that the more difficult and lengthy lower extremity bypasses to save a foot may not be done, and patients requiring them may end up with unnecessary amputations.

Still worse is something I have observed on two occasions, a "vascular specialist" advising saphenous vein ablation in patients with no varicose veins and no abnormality in their saphenous vein. In their written records of these patients, the vascular specialists described abnormal physical and Duplex laboratory findings that were not really present to justify their unnecessary interventions. Although this constitutes fraudulent practice by any standard, it is nearly impossible to detect. The description of the patients and their laboratory findings were falsified, and the normal structure that was fraudulently described as abnormal would have been ablated by the procedure. Although such behavior could be solely the result of the doctors' flawed character and ethics, I submit that decreased reimbursement for indicated procedures was contributory.

There are other negative unintended consequences of decreased doctor compensation. In the remote past, when physicians and surgeons were well compensated, many expressed their basic altruistic motives for pursuing a medical career by providing free care to the indigent. Most doctors can no longer afford to do that. Nor can most spend long hours teaching or pursuing clinical research activities, for which there are few financial incentives.

Another unintended consequence of decreased and inadequate reimbursement is the tendency for some specialists to perform procedures outside their primary field of interest because they get more bucks for the bang. This is the likely reason so many cardiac and general surgeons as well as dermatologists and others have extended their practice to include the lucrative endovenous treatment of varicose veins.

What can be done about all these unintended consequences? First the public, their legislative representatives, and third-party payers should be aware of the harmful effects of their efforts to reduce doctor compensation. They must realize that doctors are people too, and understand that they will act to maintain their incomes. Some of their actions may do little harm and be justifiable; others may not.

Our state and federal governments also must recognize the need to treat physicians and surgeons fairly. This has not always been the case, and certainly it has not happened with malpractice tort reform. Our governments have been delinquent and have wrongfully accepted the influence of the trial lawyers to block such reform. This must stop, and doctors and government must work together to right this wrong.

Of equal importance is that we as physicians and surgeons understand what is happening and be aware that we may be tempted to compensate for decreasing reimbursement in ways that do not serve patients' interests. Most doctors went into medicine to make patients better, and most continue to want to act in the interest of patients. By being aware of the harmful unintended consequences of decreasing reimbursement, we may be better able to resist the temptation to engage in practice alterations that promote these negative effects.