Pay Doctors to Make Care Affordable

DANIEL S. GREENBERG

December 15, 1992|By DANIEL S. GREENBERG

WASHINGTON — Washington. -- There's an easy way to clamp down on medical spending while providing high-quality care for all. But Bill Clinton, dedicated as he is to health-care reform, won't buy it because it would ignite hysteria in the body politic.

Here it is: Make doctors so rich that they'll forget about making money. Put them all on fat salaries, and thereby eliminate the grubby financial secret of doctors' prosperity, that the more they do, the more they get, regardless of the need for what they do.

Many saintly docs are immune to financial considerations, and confine themselves to providing only necessary services. But the economic realities of American medicine assure that many other docs are not. In fact, the present health-care system encourages TC foraging for patients -- known in other trades as customers. And it encourages doctors to prescribe tests and drugs and services, needed or not.

Hospitals, dependent on doctors for obtaining patients, court physicians who can fill beds. From the writing of prescriptions to the admission of hospital patients, doctors are the so-called gatekeepers in medicine, making the decisions that lead to expenditures.

That's why, until it became too blatantly embarrassing, pharmaceutical firms used to woo doctors with Caribbean seminars and ski-resort symposiums on their latest pills and tablets.

One firm even adopted a ''frequent prescriber'' system that awarded holiday points to doctors for prescribing its products. Now that these practices have been deemed indiscreet, the drug makers are supposed to confine their enticements to expensive dinners and ballpoint pens.

The latest controversy in medical economics concerns ''economic credentialing,'' the term for linking physicians' hospital privileges to the cash flow they generate through admissions. A thriving consulting industry has arisen to serve the quest for patients, both for office practices and hospitals. Many medical publications regularly provide advice on marketing of health-care services.

From the long-ago days of shortages of doctors, an illusion persists of physicians passively waiting for the sick and lame to seek their services. Some do wait. But, increasingly, doctors are hustling for business in a fashion that sometimes transforms patients into economic prey.

Several studies have shown that, for comparable patients, doctors who own X-ray facilities tend to order more X-rays than doctors who don't. The American Medical Association, slow as ever in cracking down on financial exploiters in the ranks of medicine, has just acknowledged that referrals to self-owned facilities may not be good practice.

To get money off the minds of doctors, the simple solution is to assure them plenty of it, from the health-care budgets of the federal government and the health-insurance industry. Pay off their school debts, too, and the country would still be getting a bargain in comparison to today's go-for-broke medical economics.

The arithmetic is simple. Physician incomes after all expenses now average about $165,000 a year. High earners are up near $1 million.

Even so, doctors' income accounts for slightly under 20 percent of national health-care spending. The big item is hospitalization, about 40 percent, with drugs accounting for 7 percent, and research, medical education, medical equipment, and other items making up the rest.

A realistic reform system would match or even exceed current salary levels for doctors, with generous annual increases, but no other income permitted from medical services. Relieved from the rigors of assuring income, physicians would be required to concentrate on patient care, without regard to generating cash flow.

As at present, the humane traditions of medicine, reinforced by monitoring by colleagues and fear of malpractice suits, would provide the incentive for medical excellence.

Patients would be advised to return for a visit only when such is medically advisable. Financial incentives would be eliminated from tests and other services. And in the crucial role of hospital gatekeeper, medical considerations alone would govern.

The simple, effective solution is waiting to be adopted. Go for it, Mr. Clinton.

Daniel S. Greenberg is a syndicated columnist specializing in the politics of science and health.

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