Surgeons prosper anew as primary care doctors and pediatricians struggle

doc-300x169The Covid-19 pandemic continues to slam the practice of medicine, with patients’ infection fears and treatment delays putting at serious financial risk the providers of crucial medical services like primary care doctors and pediatricians.

At the same time, as is too often the case in U.S. medicine, the rich may be getting richer, as resuming care gives patients eye-opening information on the big money in orthopedic and plastic surgery and other cosmetic procedures.

The coronavirus’s economic shocks may most accelerate changes — not all of them happy for patients — for primary care physicians, who account for half the annual doctor visits annually in this country, the independent, nonpartisan Kaiser Health News service reported.

The so-called “family doctors” already were under big pressure because of medicine’s “misaligned incentives.” That is the fancy way that health economists describe the dysfunctional, piecemeal “fee for service” system that prevails in U.S. health care and which primary care doctors report accounts for 70% of their office revenue.

Because they get paid for each service they provide, primary doctors find themselves needing to have sizable numbers of patients and to get them to visit a lot, and quickly, so they can charge them for an array of treatments — tallying a ticky-tack roster of procedures, packed waiting rooms, and a barrage of medical codes and bills.

The pandemic disrupted this business model, with patients fearful of getting Covid-19 infections while seeking medical care, or unable to afford their previous level of treatment due to the coronavirus economic disruptions, including huge joblessness and loss of health insurance. This has left primary care practices with projected average losses for the year of $68,000, or $15 billion across this important part of medicine.

Primary docs say the red ink may drive many out of business. Or they may be forced into medical groups, which increasingly are run by bean-counting MBAs to maximize profits, for example, for big hospitals, corporations, and hedge funds. For the sake of revenues and “efficiencies,” already stressed and even burned out primary care docs may be forced to see even more patients in shorter visits with more tests and treatments purportedly provided.

Or maybe the highly trained practitioners — knowing the nation faces a serious shortage of MDs — leap into “concierge” medicine, in which a smaller number of patients pay hefty fees, with promise of expedited and more attentive care? Or perhaps these doctors, including groups of them, develop a various of this plan, in which patients pay a monthly fee and flat visit fees. Maybe Uncle Sam is heading this direction already, KHN reported:

“Medicare’s Primary Care First program is a main vehicle in that effort. It will launch in 26 areas in January. Doctors will get a fixed per-patient monthly fee along with flat fees for each patient visit. A performance-based adjustment will allow for bonuses up to 50% when doctors hit certain quality markers, such as blood pressure and blood sugar control and colorectal cancer screening, in a majority of patients. But doctors also face penalties up to 10% if they don’t meet those and other standards.”

Such powerful government pressure on payment programs, alas, would not be of much help with another different and important medical practice: pediatrics. Kids’ docs not only have seen their business crater, they have campaigned with parents to try to let them know: 1. Their fears may be exaggerated about getting their youngsters’ care and 2. Routine wellness, vaccination, and health status checks are important for children’s well-being and long-term development.

This is what health journalist Rita Rubin reported recently about the American Academy of Pediatricians in an online article for the Journal of the American Medical Association:

“The AAP in May launched a social media campaign, “#CallYourPediatrician,” to remind parents that they should still make appointments for well-child checks and immunizations during the pandemic. Research supports pediatricians’ concerns that children have been falling behind in their immunizations. Compared with the same time period in 2019 and 2018, vaccination coverage of Michigan infants and toddlers up to age 2 years declined in January through April of 2020, according to a recent article in the Morbidity and Mortality Weekly Report. Only coverage with the hepatitis B vaccine dose given at birth, typically in the hospital, did not decrease. ‘The observed declines in vaccination coverage might leave young children and communities vulnerable to vaccine-preventable diseases such as measles,’ the authors noted.”

But even as primary care doctors, pediatricians, and obstetrics-gynecology specialists hobble along due to the pandemic, the moves to greater normality have led to greater insight about big-dollar hip and knee replacements and plastic surgery and other cosmetic procedures.

As KHN, again and in a separate news article reported, about older patients and the renewed push to get or keep their mobility via surgery:

“It’s impossible to know exactly how much knee and hip replacements are worth to hospitals because no definitive data on total volume or price exists. But using published estimates of volume, extrapolating average commercial payments from published Medicare rates based on a study, and making an educated guess of patient coinsurance, [a leading expert] helped KHN arrive at an annual market value for American hospitals and surgery centers of between $15.5 billion and $21.5 billion for knee replacements alone. That suggests a revenue loss of $1.3 billion to $1.8 billion per month for the period the surgeries were shut down. These figures include ambulatory surgery centers not owned by hospitals, which also suspended most operations in late March, all of April and into May.

“If you add hip replacements, which account for about half the volume of knees and are paid at similar rates, the total annual value rises to a range of $23 billion to $32 billion, with monthly revenue losses from $1.9 billion to $2.7 billion.”

Surgeons and hospitals, treating a graying population determined to stay active, have seen knees and hips as a booming medical gold mine, the news service reported, adding of the replacement procedures:

“They have become a cash cow as the number of patients undergoing them has skyrocketed in recent decades. The volume is being driven by an aging population, an epidemic of obesity, and a significant rise in the number of younger people replacing joints worn out by years of sports and exercise. It’s also being driven by the cash. Once only done in hospitals, the operations are now increasingly performed at ambulatory surgery centers — especially on younger, healthier patients who don’t require hospitalization. The surgery centers are often physician-owned, but private equity groups such as Bain Capital and KKR & Co. have taken an interest in them, drawn by their high growth potential, robust financial returns and ability to offer competitive prices.”

The KHN article also makes this important point:

“Acutely aware of the financial benefits, hospitals and surgery clinics have been marketing joint replacements for years, competing for coveted rankings and running ads that show healthy aging people, all smiles, engaged in vigorous activity. However, a 2014 study concluded that one-third of knee replacements were not warranted, mainly because the symptoms of the patients were not severe enough to justify the procedures. ‘The whole marketing of health care is so manipulative to the consuming public,’ said Lisa McGiffert, a longtime consumer advocate and co-founder of the Patient Safety Action Network. ‘People might be encouraged to get a knee replacement, when in reality something less invasive could have improved their condition.’”

Doctors themselves have asked tough ethical and professional questions about the urgency of hip and knee surgeries in the middle of the pandemic, it should be noted.

As for highly elective plastic surgeries or cosmetic procedures, a Hollywood trade publication reported that they have persisted as a burgeoning business throughout the pandemic — at least in Tinseltown.

The Hollywood Reporter attributes their popularity to multiple causes, including the vanity of the well-heeled and their realized desire for improvements to their appearance as they take note of it in the glare of multiple online video conference (Zoom) sessions.

Other celebrities, the entertainment journal reported, have undertaken cosmetic work during the lockdowns, knowing that they could recover with less notice and outside the public view. And some of the coast’s glam guys and gals purportedly have sought enhancement work to better their prospects in online porn — a business that has flourished during Covid-19 quarantines.

Ooof. In my practice, I see not only the harms that patients suffer while seeking medical services, but also their struggles to access and afford safe, efficient, and excellent medical care. This was an ordeal before the pandemic, driven by the skyrocketing cost, complexity, and uncertainty of treatments and prescription medications, too many of which turn out to be dangerous drugs.

If you need medical treatment, you should not hesitate to contact your doctor, immediately, and discuss your care and its safety in these troubling times. Don’t imperil your well-being with unnecessary waiting.

Health care, though, should be a right not a privilege in the wealthiest nation in the world. Alas, unjust and unacceptable inequities flourish in the American health care system and these problems only get magnified — exponentially — by its out-of-kilter economics. If we say our ideal would be for affordable and quality care for, we need to look hard at the proliferation of pricey concierge care.

Primary care doctors, pediatricians, ob-gyns, and other MDs in fields besides surgery provide invaluable services to their patients — and to the health care system overall. (You can read more about my thoughts on the importance of primary care doctors in my book, “The Life You Save: Nine Steps to Finding the Best Medical Care-and Avoiding the Worst.”) They can attend to the bumps, bruises, illnesses, and medical needs for most of us, much of the time, referring patients to more costly, time- and resource-consuming care only when needed and appropriate. The fee-for-service model makes a mockery of what many of us would consider reasonable, as does “practice creep” — in which patients turn to highly trained and costly heart or cancer specialists to also act as their primary care docs.

Yes, we should value surgeons and their practices. But we’ve raced by the time when patients swooned over knee and hip replacements, particularly if they’re over promoted sold with excess zeal and dubious claims as being light on risk and big on results. As for plastic surgery and cosmetic procedures, well, that’s a topic for a whole newsletter, isn’t it (click here to read mine). We’ve got a lot of work to do to ensure the access, affordability, quality, and safety of medicine, and maybe the pandemic will, in best case scenarios, push U.S. health care to make desperately needed reforms.

Patrick Malone & Associates, P.C. listed in Best Lawyers Rated by Super Lawyers Patrick A. Malone
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