CORONADO, CALIF.—With the healthcare landscape morphing on a near-daily basis, panelists gathered at the Triological Society Combined Sections Meeting to discuss the merits and disadvantages of the fee-for-service payment model, as well as its role in the future of healthcare in the U.S.
Members of the group touched on the importance of preserving their ability to provide patient care, the “outlier” physicians who bend or break rules for profit, and the importance of spreading awareness that a large number of factors contribute to high healthcare costs in the U.S. They tended to agree that at least some form of fee for service will continue to exist, largely because it is a good system when compared with others.
The panel was moderated by Fred Owens, MD, of the Owens Ear Clinic in Texas and incoming president of the Triological Society. Panelists were Sigsbee Duck, MD, of the Memorial Hospital Otolaryngology Clinic in Rock Springs, Wy.; Susan Cordes, MD, of Ukiah Valley Medical Center in Ukiah, Calif.; David Edelstein, MD, chief of the otolaryngology service at Manhattan Eye, Ear and Throat Institute in New York City; and Michael Setzen, MD, a solo practitioner in Great Neck, N.Y.
Fred Owens, MD
Dr. Owens said the criticism of physician billing has been growing but that patients often demand the kind of care that they’re given. “[Critics] complain a lot because we order studies,” he said. “But I would contend that it’s going to be very difficult to get patients to let us take care of them without getting studies done to try to make a diagnosis. And we’re probably the leading country in building technology, so technology usually comes first to us and then to other countries.”
Dr. Cordes listed a wide range of benefits of a fee for service system: familiarity, the simplicity of paying for what you get, promoting a physician work ethic, and allowing for physician autonomy and flexibility in lifestyle and income and in the types of procedures and practice they want to perform. “Ultimately, I believe that fee-for-service could actually decrease healthcare costs because it is like the market where, [when] you need something, you have to pay for it,” she said. “If patients have a little skin in the game on everything, then they will be better consumers and make better choices and participate more in that decision, and that could help hold costs down.”
Cost, Volume, Value
Dr. Setzen said he thinks that fee for service that involves quality-based and value-based measures would be a fair and reasonable approach to care. According to Dr. Duck, if appropriate and meaningful quality and value measures were added to fee for service, there would be a method by which to prove that what you’re doing is working. “That’s the big downfall with fee for service, according to all the papers and studies that are published,” he said, adding that most of the articles about why fee for service isn’t a good system are written by non-physicians.
Dr. Edelstein, playing devil’s advocate, said the main criticism is that it’s thought that fee for service is high cost and high volume but not high value. “We have a poor life expectancy in the United States amongst all the developed nations, and high infant mortality. And the question is ‘Why?’”
Dr. Setzen said life expectancy and infant mortality might not be the best indicators of the quality of a health system. For example, in the U.S., physicians take on high-risk pregnancies that might end with the death of the infant shortly after birth, whereas in another country the fetus may die in utero and be stillborn, and this does not affect their infant mortality statistics. Similarly, life expectancy statistics are flawed, he said.
Outliers
The panelists spent a fair amount of time talking about physicians who abuse the system by billing for work not performed. They agreed that these physicians might be “outliers,” but they do exist and help tarnish the reputation of the entire medical field.
Susan Cordes, MD
Dr. Cordes said that such physicians account for just a small percentage of medical professionals and she doesn’t think that healthcare costs will significantly decrease if fee for service is eliminated. Most tests and procedures are needed for good healthcare, she said, and physicians would still want to take good care of patients, with or without a fee for service system.
This was a point that drew passionate remarks from the audience.
Mark Persky, MD, director of the head and neck center at New York University Langone Medical Center, said the panel was “biased” and that it would be worthwhile to bring other voices outside the physician world into the conversation. He also challenged his colleagues to confront physicians who abuse the fee-for-service system.
Stilianos Kountakis, MD, PhD, chair of otolaryngology-head and neck surgery at Georgia Regents University, said that might not be such a straightforward proposition. “Medicine is not an exact science. It’s an art. There are different options,” he said. “So I think if we keep going on saying our communities are filled with physicians who abuse insurance companies and patients, without bringing up specific methods or ways to handle that, I think it doesn’t lead to anything good.”
Dr. Edelstein disagreed with the notion held by some outside the physician world that fixing healthcare is a matter of collecting more data to determine the care with the best value, and that policy could simply be changed based on that data. “The assumption that somewhere there’s data that physicians are hiding is just a ridiculous concept,” he said.
He also said it is crucial that physicians work together, even though that has not traditionally been a practice. “Individually, we’re all going to be like those little grocery stores on every corner in New York City that have really gone the way of the looney bird,” he said. “That’s why we’re under attack, because as much as we’re smart in this room, we don’t have the ability to negotiate as a smart group.”