A ReLACSing Blog #3: Why I’m Leaving the Fee-for-Service Healthcare System, Part Beta
Last week, I told you “I’m done with this place” and leaving the fee-for-service healthcare system for direct specialty care. The fee-for-service system pays for procedures and not prevention. It pays to do things to people for a problem and not for the process of improving the health problem. “Doing things” is not necessarily the best for diagnosis and treatment of illness, but the system pre-conditions doctors to err on the side of doing things, because it makes money. “Doing things” rarely works for prevention of disease. Because of the focus on tests and procedures, the system feeds into waiting for people to get sick before intervening as the prevention of the condition requires significantly more time and energy. I always chuckle when politicians talk about the cost of insulin and drugs for type 2 diabetes, which is a preventable and often reversible condition through lifestyle change. You do not hear them talking about reducing the cost of diabetes treatment by putting the resources into prevention and lowering the number of Americans with type 2 diabetes, a condition that hardly existed prior to the mid-18th century when refined sugar entered into the food system. One of newest technologies for prevention and mitigation of diabetes is the continuous glucose monitor (CGM) that gives real time blood sugar levels that could directly provide feedback on how food and other activities directly impact blood sugar levels so people can learn and prevent spikes and dips in blood sugar levels. However, this is rarely covered by insurance unless a patient has progressed all the way to requiring insulin for type 2 diabetes, which is far too late in the process. Yet, insurance companies may actually pay for the more expensive diabetes medications to treat the diabetes that is progressing. Again, this illustrates a focus on treatment of disease over prevention.
Thankfully, there are a couple of systems emerging to buck this pattern. The capitated system for healthcare coverage is expanding. In this system, medical groups get paid a set amount up front to care for their patients. They can take the money and do what it takes with those resources to prevent health conditions and hospitalizations. The more that is prevented, the more that can be saved from doing all of these expensive procedures. In other words, they save money by avoiding an unnecessary procedure, instead of getting paid more by foisting another questionable test onto their patient and their third party payer. Rather than making money by running hospitals at capacity, they can make money by keeping their patients healthy so they do not get admitted to the hospital in the first place. Keep an eye on this model, as some version of this may be the solution to our crisis.
Another model is the Direct Primary Care (DPC) model in which you pay a reasonable subscription fee to get personalized and dedicated care from physicians that have time and resources to prevent and treat illness without the need for running up the tab with marginal procedures or triaging to a cadre of specialists. Obviously, I am not a primary care physician, but I have chosen to adopt the DPC approach to care by starting a direct specialty clinic in sleep medicine. By removing the barrier of the business between the medical center and the insurance industry, I will be free to manage patients with the liberation to blend the significant knowledge and expertise I have in sleep medicine with additional time, energy, and availability to serve patients well. Direct specialty care, or DSC as it is sometimes called unofficially, does not make a lot of sense financially for many specialists as their procedures and tests are heavily rewarded within the fee-for-service model. This is why DSC is less common than DPC currently. For the average medical center, the specialist is one that generally makes the revenue, whereas the primary care doctor’s role is often to be there to generate referrals to these profitable specialists. Some major medical centers have abandoned primary care altogether and rely only on the doctors in the community to refer patients to their specialists. Others offer primary care only as a means to bring patients into the system to lead the patients to their specialists, like the poor kid at the intersection holding up the sign and dancing around to advertise for the coffee shop inside the strip. Have you seen some of these stand-alone surgery centers on the side of the freeway? I’m guessing they do the procedure, get the insurance money from it, and provide little else in the way of healthcare or maybe never see the patient again.
However, there are indeed specialists that are not linked to profitable procedures. Think of rheumatologists and endocrinologists. There are not many profitable procedures to prevent inflammation for a rheumatologist. Making lifestyle interventions to slow and reverse the course of diabetes does not involve any fancy diagnostic test for endocrinologists. In my primary specialty of neurology, there is a dearth of cognitive and behavioral neurologists specializing in dementia, for example. No procedure to do, highly labor intensive, lots of education and counseling, no money in it from the insurance. Other subspecialties of neurology have started to cling to procedures: neuromuscular neurologists do a lot of nerve and muscle testing (EMG-NCS), seizure docs do tons of EEGs and epilepsy monitoring unit hospital stays, Parkinson disease specialists get involved in fancy deep brain stimulator surgeries, migraine specialists focus on injections and Botox more than lifestyle changes to prevent migraines.
Sleep medicine is no different. The entire subspecialty is geared toward the overnight sleep study (polysomnogram or PSG) because that is what pays from insurance. The main condition to justify a PSG is obstructive sleep apnea (OSA) as this one can be assessed quickly, leading to the money-making diagnostic test, and then a mostly easy treatment (CPAP) (in principle, easy), and then not much to do after prescribing the CPAP (except for those who are struggling…but who cares, the money is already made), and then you can move onto a new set of patients. The way the sleep clinic patient schedule is set up is to see patients in a short period of time and generate as many overnight sleep studies as possible. If the patient happens to have, God forbid, a second sleep concern, whether insomnia, excessive daytime sleepiness, RLS, acting out dreams (e.g. REM sleep behavior disorder), or a biological clock problem, that’s going to slow things down so you want to avoid those patients. They may even have to schedule a follow up visit which takes away time from new patients and more studies. Thus, to avoid wasting too much time with these other conditions, all of which are time-intensive and counseling-based, you resort to short cuts. Here’s your sleeping pill for insomnia, see you in six weeks. Sleepy during the day? You can do a super-expensive test like the PSG and MSLT, which is an overnight sleep study followed by a series of daytime nap tests, so you can bill the insurance even more. The test results for the MSLT will be unhelpful, (and more unhelpful here), but then you can prescribe a stimulant and not worry about educating the patient and making changes to behavior. Meanwhile, talking to the patient and restructuring their sleep is off the table, and the one diagnostic test that may be of value (actigraphy) is not covered by insurance (even though it’s like 5% to cost of a PSG), so why bother? I could go on. I have not conformed to this pattern and have struggled to work in a system like this for 7+ years, but no more. I’m done with this place.
I am excited to launch ReLACS Health, a direct specialty care service. This is a new era to my career and a path that will not compromise my values as a physician under the metrics of efficiency and billing. For those of you who want more help beyond the status quo approach suited to straightforward obstructive sleep apnea, you are welcome to be a part of this practice. I have found a new home outside the fee-for-service system, because, as my son liked to say, “I’m done with this place!”
-Andy Berkowski, MD
ReLACS Health
