What are your thoughts about self referral practices by doctors? I recently wrote a post about a being asked to do a preoperative evaluation on a healthy 34 year old pig farmer I felt was unnecessary. The request came from another physician who had a PA written level 3 H&P done three hours previously. I felt the request was medically unnecessary. However, I concluded that the patient's private insurance would pay for my consult because it met the 3 R (request, reason, response) requirements of consultative services. A reader suggested that I was part of the problem for providing a service I felt was medically unnecessary.
jcmd Yesterday 04:43 PM
My position on that is it doesn't matter whether I think a service is medically necessary or not. Medical necessity is an insurance concept used to determine payment of services rendered. It is not a medical issue. I am not being asked a question by a surgeon to determine medical necessity. I am being asked to evaluate a patient for pre operative stratification.
I have no idea what the surgeon knows. For all I know, he is so ignorant on the risk stratification of his own healthy patients he needs an internist for everyone. The same issue occurs with consult requests between different specialists and subspecialists all the time. When an internist asks for an orthopaedic consultation on a shoulder dislocation they are requesting the consult either out of laziness, fear or ignorance. When an ENT doc requests an internist for management of stable diabetes on pills only, they are requesting out of laziness, fear or ignorance. The judgment of medical unnecessary is a judgment from those with knowledge about those who may not have that knowledge.
That's why I suggest fee for service rewards those with less knowledge and penalizes those with more because everything gets paid for regardless of how little or how much you do. This is why I am a huge fan of bundling care to reward those that practice great medicine and take care of their own risk stratification or their own stable diabetes instead of costing $250 for another doctor to take over.
The reader goes on to suggest that my willingness to do a consult I think is medically unnecessary is the same as the self referring practices of doctors doing procedures. I think that statement is completely false. Both add unnecessary cost and drive health care inflation. That's true. But in the first case, I have no way of knowing what the baseline intelligence of the doctor is. Whether they are requesting the consult out of laziness, fear or ignorance. In the self referral game, the doctor knows their threshold for all three. And they can use that to their advantage AND benefit through unlimited self exploitation to those ends. Because Medicare pays every time. Because everything will always be medically necessary. That's the nature of our fee for service.
That's why I think the medical necessity threshold for payment is a scam resulting in uncontrolled health care inflation. We doctors order the tests for just about everything. We are a big part of the problem in health care inflation. I read once, and I can't find the source, that Medicare denies claims based on medical necessity close to ZERO percent of the time. Either doctors are always right or medical necessity simply cannot distinguish good care from more care.
I despise this type of self referral practice because I know someday I will be a patient as well. And I hate to think, knowing what I know, that doctors will do stuff to me that generates profit instead of practicing right medicine. Will they operate on me or image me or stick catheters in me because they can? I can understand ignorance. If they do it out of ignorance, they should be punished by making less money, not more. That's what bundled care will do for you as a patient. If they do it out of fear, they should spend more time with their patients explaining the risks and benefits and doing what the evidence says they should. We should not pay for the fear of others. If they do it out of laziness, they should be paid less for their care. That's what bundled care will do for you as a patient. If they do it out of greed, they should not be rewarded with more money.
You can make profit and practice good medicine by reducing the cost of care for everyone. That's what bundled care can do, if it's paid for with algorithms that encourage evidence based practice and encourages efficiencies of scale and lets the doctors decide the most efficient and cost effective way to deliver the right care. Right now in our fee for service model, everything is always medically necessary. Nobody has any incentive to think and think well. The easiest way is often the most expensive. Our ability to provide quality care, for the masses, comes at an expense that is neither rational nor sustainable. Something must change in the way we offer care before nobody can afford any of it.
I think the solution comes in bundling.
