Earlier this week the Happy Hospitalist, an internist who works full-time in a hospital, published a behind-the scenes look at the “turf wars” that doctors fight when it comes to performing certain very lucrative procedures. Colonoscopies, for example, pay nicely, and doctors vie to do them. Bone marrow biopsies, on the other hand, belong to the group of procedures he labels the “red headed step children” of hospital care: they’re relatively time-consuming and just don’t pay very well. As a result, the (usually) Happy Hospitalist explains, he often has a very tough time finding a specialist willing to perform one of these procedures for a patient.
Let me preface his story by pointing out that Medicare’s fee-for-service payment schedule—which has become the basis for most private insurers’ payments as well—is set and updated by a proprietary, and rather secretive advisory committee, the RVS Update Committee (or RUC).
I’ll tell you more about the RUC in the post below (“Who Decides How Much To Pay Specialists?”) But first, read the Happy Hospitalist’s story. (Note, throughout the piece, I have inserted definitions of medical terms, in brackets.)
From: The Happy Hospitalist
TUESDAY, JANUARY 8, 2008
“Red Headed Step Children”
“In the world of procedures, all procedures are not created equal. And when that happens, the turf wars begin. I can assure you, in just about every hospital in this country, behind the scenes politics go hand in hand about who has the right the perform what. The battles usually ensue in those procedures that are economically worth while to the doctor or group of doctors
“There are some procedures that are not "owned" by specialties. [Other]
physicians get credentialed to perform a whole host of procedures.”
The Happy Hospitalist then lists some of the procedures he learned to
execute while he was training to become an internist or primary care
doctor:
- Central lines [a catheter or IV passed through a large vein]
- Lumbar Punctures [puncturing the area between the lowest ribs and the pelvis or hip]
- Thoracentesis [inserting a hollow needle to remove fluid from the cavity of the chest]
- Intubation [inserting a tube into the larynx]
- Paracentesis [tapping a body cavity—usually the abdomen—to remove fluid]
“This was part of my training as a resident, to become proficient in
these types of procedures. For other residencies, the expectation of
proficiency was determined by the specialty and the program…
“When you go out into practice, your record of experience may be called
up for ‘proof’ by your new hospital that you know what you are doing
when you do any type of procedure. Placing a needle in hollow spaces.
Sticking a scope in hollow spaces. Putting a catheter in a blood
vessel. I can’t really speak for surgeons, but I would think their
credentialing requires proof of numbers of surgeries as well.
“But as you know, not all procedures are owned by one specialty. I do
central lines. Surgeons do them. Anesthesia does them. FP [family
practitioners] do them. I’m sure pediatricians can do them as well.
Nephrologists do them. . . . FPs, surgeons, internists,
gastroenterologists” are all trained to do colonoscopies” as well.
“These are just some examples of procedures which are credentialed by
different specialties. The problems occur when battle of the ‘turf
wars’ begin.
“In my 5 years as a hospitalist, I have seen turf wars develop for different procedures.” He list some examples:
- PICC lines [a line inserted in a peripheral vein and then advanced, through larger veins]
- Vascular intervention [interventions involving vessels that
contain fluids like arteries and veins, often using a stent to prop
them open] - Colonoscopies [examination of the inner surface of the colon]
- Vascular study evaluation [evaluating how well arteries and veins are functioning.]
“I’m sure there are others. And I’m sure there are turf wars at hospitals all over this country. Ours is no exception.
“But why?” he asks.
“My assumption is that it’s about money. The battle for that Medicare
Dollar from the Medicare National Bank. These types of procedures pay
well, relative to the risk involved, volume generated, time spent and
payment for alternative encounters of care [i.e. primary care, a.k.a.
“listening to and talking to a patient” without necessarily performing
a procedure.]
“Now granted, extra training is required in specialty training and with
that extra training comes the benefit of higher income. Of course that
is accepted,” the Happy Hospitalist acknolwedges.
But, he notes, “What I find highly interesting is that not once have I
ever heard of a turf war developing in the following procedures which,
like angiograms, colonscopies, heart caths, etc require a level of
repetition and expertise to limit complications:
- Thoracentesis [inserting a hollow needle to remove fluid from the cavity of the chest
- Paracentesis [tapping a body cavity—usually the abdomen—to remove fluid]
- Lumbar Puncture [puncturing the area between the lowest ribs and the pelvis or hip]
- Bone marrow Biopsy [removing soft tissue from inside the bones]
“In fact, often times I find it very difficult to find any specialist
in their field of expertise who will perform these procedures for my
patients. To me, the reason is obvious. Money.
“The Medicare National Bank pays these procedures at an approximate
rate of a level 2 hospital follow up visit. In other words, it ain’t
worth the time for most specialists. (A level two follow up visit can
be documented on paper in about a 10 minute visit. Tops.)
“These are procedure that have been handed over to the interventional
radiologists [doctors who specialize in minimally invasive targeted
treatments] or me (if I’m comfortable) or my partners (that are
comfortable) because it is not worth the opportunity cost of that time
for my specialists to do it. I will occasionally get lucky and find
docs to do it. The pulmonologists are especially good about doing their
own throacentesis. But in general, the opportunity cost of doing a
paracentesis is a colonoscopy that pays 3 times more in about the same
period of time.”
But, he asks: “Why should I have to send a patient of mine to get a
lumbar puncture by an interventional radiologist who may use
fluroscopy, has a whole team of nurses and will likely bill out an
extra ordinary facility fee for the use of all that great technology
when the specialist, who learned that skill in their training, can do
it quite quickly and comfortably at the bed side?”
In other words, when the interventional radiologists perform the
procedure, it becomes more expensive than if it were done by the
specialist who has been trained to do it easily, right at the bedside.
The Happy Hospitalist answers his own question: “It’s because these
procedures have been labeled the Red Headed Step Children of the
Procedure World”
“They are the primary care of the procedure world.” In other words,
like primary care, these are the procedures that don’t pay well.
“I would also like to know why I can’t find a single gastroenterologist
in 5 years in my town that will take the time out of their busy day to
do a paracentesis on a patient of mine, a procedure they trained for in
their 3 extra years of specialty work, but will kindly spend all day in
the endoscopy lab? [endoscopy—using a camera mounted on a flexible tube
to look for diseased tissue].
“I think you all already know the answer why. At least at my institution, this is my experience.
“No offense to red headed step children,” he concludes. “Please don’t flame me for that. It was a figure of speech.”
My advice: the next time someone urges you to have a colonoscopy, you
might want to ask yourself, is this about my colon, or the fee
schedule? For an excellent, evidence-based discussion of the
controversy about just how often patients should have a colonoscopy,
see Gary Schwitzer, at the HealthNewsReview.
In my limited experience with a bone marrow biopsy and a colonoscopy I have to wonder if the pricing reflects the patients likelihood of being a frequent customer.
If you’re having a BMB you are likely sick and will be coming back for more.
A colonoscopy is mostly a one-time thing. You are much less likely to be back to that Dr. soon.
Maybe the Happy Hospitalist can’t find anybody to do certain procedures because they know his patients aren’t likely to come back to them for the rest of their treatments — whose fees will make up for the low paying procedure.
I think of it like the old phone days when Ma Bell overpriced long distance and under priced local service. Once that ended then the world of phone service exploded and generally costs fell.
your procedure definitions could use a little extra work. 🙂
also, to the above poster. colonoscopies are screening tests for cancer. you get screened periodically, although how frequently is certainly up to debate. they also look for bleeding sources, many people who bleed, bleed more than once.
please read the comments in the happy hospitalist blog. s/he concedes that s/he was trained to do the procedures in question. so the question might as easily be-why isn’t s/he (hospitalist)doing them her/himself instead of calling specialists to do them?
could the price be lower since the available pool of trained physicians is much larger?
your procedure definitions could use a little extra work. 🙂
also, to the above poster. colonoscopies are screening tests for cancer. you get screened periodically, although how frequently is certainly up to debate. they also look for bleeding sources, many people who bleed, bleed more than once.
please read the comments in the happy hospitalist blog. s/he concedes that s/he was trained to do the procedures in question. so the question might as easily be-why isn’t s/he (hospitalist)doing them her/himself instead of calling specialists to do them?
could the price be lower since the available pool of trained physicians is much larger?
Anonymous, procedure reimbursement goes up when a specialst does it, and the hospital can bill more. i.e. I am a family doctor who did obstetrics until about a year ago, the OB/GYN doctor got paid up to $500 more to provide the exact same service I provided!! In the hospital where I work only the gastroenterologists do paracentesis (when you have fluid in your abdomen that needs to be drained), but they sent a PA to do it! there was a big turf war in my last year there, the hospital almost made it so only the cardiologists and er docs where allowed to read ekgs!!! because cardiologists make more for the hospital reading the ekgs, and if they filtered all the ekgs to the cardiologists the hospital stood to make a great deal more off of them, mean while the stress tests performed in the hospital where done by a PA. sadly the art of medicine is rapidly giving away to the economics of medicine.
i don’t know your situation, but i know mine.
in our area, everyone does not get paid more for reading ekg’s. nobody wants to read them. as far as the hospital charges, could it be that the locations of the ekg’s differ? or that they make more money because more tests get ordered as a result? or is it truly apples to apples? i’ll ask our people and post next week.
also, i’m not sure who is ‘allowed’ to do what. are you stating that they created a new policy that disallowed people from doing procedures that they had been doing if they were not certified in some fashion?
we actually want the primary care docs to survive in our hospital. they were offered the opportunity to do stress tests, and most stated that they did not want to. even the hospitalists. what can we do about that?
as far as paracentesis, see the ongoing discussion with happy hospitalist. i don’t believe the hospital administration would deprive someone adequately trained to do them (primary care docs)the opportunity, but like i say, i don’t know your situation. or are you just saying you don’t like a pa performing the procedure??
Everyone–thank you for your comments-
Ginger- In the post that follows this one, I describe how the fee schedule was designed and updated.
Whether the patient will come back doesn’t enter into how the fees are supposed to be calculated (based on stress involved, physical effort involved, etc.) I suppose this fact could have an implicit or subconscious effect on what specialists are willing to accept for certain procedures. But according to Happy Hospitalist it doesn’t work that way at his hospital- specialists still don’t want to do bone marrow biopsies even if the customer will be coming back.
Dr. Matt– I think you’ve hit the nail on the head: the art of medicine is quickly giving way to the economics of medicine. I hadn’t thought about it, but of course hospitals can make more if certain specialists do certain jobs.
anonymous–I’m afraid only happy hospitalist is in a position to answer your questions
Interesting discussion, I find it very interesting because the situation is soon going to change. Since Antibiotic was invented, we (doctors) have been very comfortable to carry on doing procedures. Some necessary and others not so necessary. Blood tests are often requested even though there is no logical explanation why it is necessary. Clinical medicine has become a thing of the past as most of us have been depending on investigation and legally defendable medical practice.
MRSA is soon going to change every thing and this may end the so called “Nobel Profession”. Introducing infection into patient which can endanger his / her life is not a simple matter. This is likly to be an important ethical issue which is likly to become a legal problem.
In UK, the Govt has issued a statement saying they are planning to penalise hospitals with high rate of MRSA infections. Studies conducted in UK and other healthcare providers to reduce infection rate has clearly shown the environment (dirty hospital), busy units and high level of temporary staff has no increase to infection rate. Bacterial colonization and poor hand washing technique, practical procedures carried out by doctors & nurses in the hospitals are associated.
Now it will be interesting to see who would have the courage to perform any practical procedures (especially in USA) in patients, no matter how lucrative it will be.
The “stepchildren” analogy is very appropriate because these procedures are very much like children from a previous marriage who are neglected. One other thing these procedures have in common is that they’re old, established and low tech.
The newer procedures aren’t so new anymore but went through a relatively recent phase when they took longer and only a few people had the training to do them. The fees don’t go down, however, as they become easier to do (because of greater knowledge and technical improvements),
Marc and Dr. Srivatsa
Good to hear from you.
Marc,
What you say makes sense. The newer procedures were paid a higher fee at a time when they took longer and fewer people knew how to do them.
Now that they take less time, the fees should be downgraded, but it’s understandable that specialists who are paid free-for-service are reluctant to do this.
This is an area where Medicare definitely could save some money –without reducing quality– by having specialists who are Not paid fee-for-service adjust the fees . . .
Dr. Srivatsa,
I think we are going to see more penalties for avoidable infections in this country as well.
When the problem is as basic as less-than-careful hand washing, everyone realizes that there is no excuse for the number of infections in our hospitals. But I would add that we also need to fill the many empty nursing slots at our hospital–the average hospital in the U.S. has 8% of those slots open at any given time.
That puts pressure on nurses and other staff, and probably leads to people cutting corners as they might be as they rush around trying to fill in for those missing nurses.
My impression is that, in some places, nurses need higher pay, but in many places, the big problem is working conditoins. Too much chaos. Too much stress.
I welcome comments from nurses about what needs to change to make more nurses willing to work in U.S. hospitals.
just want to point out that fees are adjusted downward all the time, including newer procedures.
see dr. wes’s post on electrophysiology procedures-he’ll take a 20% revenue drop from decreased reimbursement for the same procedures he did last year.
anonymous-
You’re right; fees are downgraded. But according to MedPAC’s chairman, they are upgraded much more often than they are downgraded because the majority of the people making the decisions represent a group with a financial stake in raising fees.
anonymous-
You’re right; fees are downgraded. But according to MedPAC’s chairman, they are upgraded much more often than they are downgraded because the majority of the people making the decisions represent a group with a financial stake in raising fees.
are you comfortable with the use of the word because in your statement?
could you provide a link?
thanks much
I think of it like the old phone days when Ma Bell overpriced long distance and under priced local service. Once that ended then the world of phone service exploded and generally costs fell.