Sunday, January 15, 2012

What appears to be axiomatic, may not be as obvious as it seems.

1 Jan 2010, Medicare cut cardiology reimbursements by an average of 40%. Most disheartening in this action was the support of as many as 20 medical sub speciality groups who felt that cardiology was being over compensated for its services.

I recall my own distress in the 1990's when it became fashionable to discuss the merits of medicine as a business instead of as a calling. I never favored this transformation then or now and consider this world view abhorrent and depraved. But for the sake of rhetorical argument, assume such a world view were valid, what legitimate business can withstand a 40% cash flow reduction occurring over the space of a month?

The net result of this pay reduction, a reduction particularly hard for cardiologists to absorb because a large proportion or rather the majority of cardiology patients are Medicare beneficiaries is that in the space of 6-9 months virtually every cardiologist in the city of San Antonio Texas became an employed physician.

What honest well run business has a profit margin of 40% and can withstand this magnitude of cuts? The answer is clear cut, no honest business can withstand this type of disruption. So it seems axiomatic to me, that the only independent survivors of such a draconian pay adjustment has to be those who systematically, efficiently, and cold bloodily cheat Medicare. What is the intention of health planners that they wish to benefit the cheaters while handing an unfair business advantagego the most egregious cheats of the health care system? To quote Christine Lavin 'What Was I Thinking,' (http://www.topshot.com/dh/WhatWasIThinking.html), or rather What Where They Thinking.

One of the causes of professional pride that I have had as a cardiologist, is watching the immense and unprecedented progress that my primary field of practice has wrought in the area of lives saved and function preserved. The relentless progress against the impact of the premature MI on the lives of Americans is a remarkable and singularly impressive accomplishment. In the era of the development of the 1st CCU's the 1960's the chances of death in the 1st month of an acute MI was about 30%. In the 2010 decade the 30 day mortality rate for AMI, all ages all comers is probably in most areas of the USA < 5-7%. I can't think of any other area in the field of medicine in which such impressive gains have been made with respect to mortality and morbidity outcomes.

In order to achieve these results many many physicians have had to labour day and night for decades to make the discoveries and implement the techniques required for these results to have become the norm rather than the exception.

As a physician who has dedicated most of my life to honing the skills that help me get these types of results for my patients, it took 4+4+3+4 years of academic and supervised practice experience prior to my independent practice of cardiology. Once this rigorous training is completed, the rewards for this investment, is a lifetime of what others may see as inconvience and sacrifice and possibly early death due to extreme job stress. The first law of cardiology, is that we all are only one heart beat from eternity. This realization and the fact that many of the patients that I have cared for over the years needed diagnosis and treatment delivered in the space of not hours but rather minutes and occasionally within seconds extracts a toil on the practitioner, unless of course you really are indifferent to the fate of those that fate and circumstance have placed in your path.

It is fashionable to decry the salaries of physicians in the context of making changes in American healthcare (commonwealthfund.org/Publications/In-the-Literature/2011/Sep/Higher-Fees-Paid-to-US-Physicians.aspx) The comparisons of physician salaries seems to me pernicious in that while medical education is paid for in most advanced societies (England, Germany, Australia) and practice costs and practice burdens are shouldered by the government rather than the physician, but equally important the practice hours of these nations are capped at a reasonsable work week.

I know of no cardiologists (personally) who work less than 60 hours per week. In my own case when I left the US Military, I spent 8 years in solo practice as the only cardiologist and intensivist residing in a two county area of rural Texas with a service population of approximately 80000 patients. I had two weeks vaction every four years of those eight years and was on call 24/7 for that entire time frame working a minimum of 120 hours per week. I made about $400,000 per year in a good year, but these were the two poorest counties in the state and at least 1/3 of my provided services were never compensated for in any fashion.

Was I overpaid for my work? From my basised viewpoint I don't believe so, but I no longer do that job, I can't afford to do it, compensation for my services were cut without consideration for the needs of my communities.

The practice became a casuality of health care reform, something I passionately support, but which had unintended adverse consequences for those I used serve.

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