Reinhardt responds to Salgo

Everybody's favorite health care economist, Uwe Reinhardt, sent in a letter to the editor responding to Peter Salgo's New York Times Op-Ed "The Doctor Will See You for Exactly Seven Minutes".  Reinhardt takes issue with the blame game:

Dr. Salgo also says that "publicly traded H.M.O.'s, for example, began restricting doctors to an average seven-minute 'encounter' with each customer." I defy him, or any doctor, to produce a memorandum from an H.M.O. to that effect.

During the 1990's, H.M.O.'s did extract discounts from doctors. To keep their income at previous levels, doctors voluntarily shortened visits. The H.M.O.'s were not to blame.

Finally, the average length of hospital stays started declining in the mid-1980's, after Medicare began paying hospitals a flat fee for each admission. Hospitals found it profitable to voluntarily reduce the length of stays.

Another letter echoes part of these sentiments -- that it's not up to patients to enact change, but that doctors need to take more responsibility for the deterioration of the doctor-patient relationship, because they didn't do enough to stop changes in the first place.

UPDATE:  Roy Poses of Health Care Renewal offered some thoughtful comments:

With all due respect, Prof. Reinhardt is quibbling.
Clearly managed care (and Medicare) have periodically either cut reimbursement for office visits, or have failed to raise reimbursement to keep up with inflation. Also, they have imposed ever greater bureaucratic burdens on office practitioners that increase their overhead...See this article that shows that primary care physicians' charges (reflective of patient volume) have increased much faster than their compensation, which has failed to keep up with inflation:
http://www.ama-assn.org/amednews/site/free/bil10920.htm
For Reinhard to call physicians' responses to managed care and government practices "volunary" is sophistry.  Furthermore, I wonder if perhaps Prof Reinhardt's thinking is being influenced by his conflicts of interest?

Comments

[Amy Tuteur]

'Dr. Salgo also says that "publicly traded H.M.O.'s, for example, began restricting doctors to an average seven-minute 'encounter' with each customer." I defy him, or any doctor, to produce a memorandum from an H.M.O. to that effect.'

Professor Reinhardt is wrong (again). While I cannot produce a memo about 7 minute office visits, I can tell you that I was called on the carpet by an executive at the HMO where I worked. He complained that I had come to the attention of the HMO because I let too many new mothers stay in the hospital more than the (then mandated) 24 hours. Furthermore, they had noticed that in treatment disputes between the HMO and patients, I sometimes took the side of the patient. As I recall, the administrator asked me if I was "aware of who I work for?". I told him that I knew the HMO wrote my check, but I worked for the patients. I left the HMO shortly thereafter.

Unfortunately, it was out of the frying pan and into the fire. I joined a private practice that had calculated that at the then current reimbursment rates paid by insurers, you could not make a profit if you allowed office visits to extend longer than 7 minutes. The medical aides were instructed to page us out for "emergencies" if we got so carried away talking to the patient that we forgot when the 7 minutes were up. It wasn't very long before I left that practice.

The fundamental point, which Dr. Reinhardt would be naive or foolish to dispute, is that HMOs and insurers continually interfere with the doctor-patient relationship and force doctors to compromise the care of their patients.

[Roy M. Poses MD]

With all due respect, Prof. Reinhardt is quibbling.
Clearly managed care (and Medicare) have periodically either cut reimbursement for office visits, or have failed to raise reimbursement to keep up with inflation. Also, they have imposed ever greater bureaucratic burdens on office practitioners that increase their overhead. Since visits are reimbursed by arbitrary codes that do not fully take into account the effort spend on behalf of the patient, the only recourse physicians have had is to increase the number of patients they see to try to at least keep up with inflation.
See this article that shows that primary care physicians' charges (reflective of patient volume) have increased much faster than their compensation, which has failed to keep up with inflation:
http://www.ama-assn.org/amednews/site/free/bil10920.htm
For Reinhard to call physicians' responses to managed care and government practices "volunary" is sophistry.
Furthermore, I wonder if perhaps Prof Reinhardt's thinking is being influenced by his conflicts of interest?
After all, he is on the boards of directors of a variety of commercial health care firms, including Boston Scientific, a device manufacturer,
http://www.bostonscientific.com/about_bsc/leadershipOverview.jsp?task=tskLeadershipOverview.jsp&sectionId=2&relId=1,11
Triad Hospitals, a hospital system,
http://www.triadhospitals.com/custompage.asp?guidcustomcontentid=%7B689ED322-C4AF-11D4-81F5-00508B1249D5%7D
and
Amerigroup (which is a managed care company),
http://phx.corporate-ir.net/phoenix.zhtml?c=122199&p=irol-govBoard
That means Prof Reinhardt has fiduciary responsibility for at least two companies, Triad Hospitals and Amerigroup, that might benefit were physicians to receive lower fees.

[Roy M. Poses MD]

Thanks, Kate.
Some of the links above somehow got truncated.
So please see a longer version of this on Health Care Renewal:
http://hcrenewal.blogspot.com/2006/03/economist-puts-down-physicians-cri-du.html