Ridiculous Study of the Week: Try My Better Hamster Wheel

A study just came out showing that paying more for Medicaid patients doesn’t entice doctors to take any more Medicaid patients. You don’t say?

Boosting Medicaid payment levels did not incentivize primary care physicians (PCPs) to accept more patients with the government-sponsored health insurance, a longitudinal analysis of claims data for over 20,000 physicians revealed.

A few observations to start this off.  I looked at the study briefly and it really doesn’t make sense.  If a doctor is employed and is paid by an RVU system then it doesn’t matter if Medicaid is paying her employer more as she gets remunerated the same.  In other words, the doctor doesn’t care as she just sees the patients in front of her.  So the doctor isn’t the rate limiting step here.  It seems to me that the employers or hospital systems should be the ones scrutinized over this.

Also, there is no mention that Medicaid patients are really hard to care for.  Let’s be honest.  We all know it. I am not saying that every Medicaid patient is difficult in complexity or baggage but on the whole they are a much more difficult population.  I worked in a FQHC for 10 years so I have a lot of experience in this.  So would a private doc open to Medicaid patients if she is “almost” being paid the same as Medicare?  Probably not.

My favorite part of the piece, however, is what I really want to highlight.  Another ivory tower idiot had to tell the world how to fix this problem.  This one from Harvard Medical School:

Allan H. Goroll, MD questioned whether an increase in fee-for-service (FFS) reimbursement is the appropriate way to incentivize Medicaid participation. “This is not to deny that an astronomical increase in evaluation and management valuations might have some result, but certainly not the aforementioned raising of FFS pay from an impossibly low Medicaid level to an undervalued Medicare level,” he wrote. Goroll noted that methods meant to increase volume will have little effect on practices that are already overloaded or caught in the “hamster wheel.”

Yes, the dreaded hamster wheel.  Docs are dying out there trying to finish their day.  The last thing they care about is adding more difficult patients.  Maybe he is onto something.  Maybe he will recommend DPC?  Then it goes on:

The current FFS payment model, he wrote, is derived from recommendations by the “specialty-dominated” American Medical Association’s Resource-Based Relative Value Update Committee, which “has routinely undervalued primary care evaluation and management services for decades, forcing primary care practices to maximize volume to stay in business.”

Exactly, he does get it!

He pointed to other payment models, such as one he helped develop that substitute FFS with a prospective, risk-adjusted comprehensive payment for delivery of comprehensive care. While a base payment covers practice expenses, a bonus payment is tied to specific patient- and cost-related measures.

And my bubble is officially burst.  I always underestimate the egos of these pompous jerks.  He actually is pushing a payment model he developed! And what is his system? It’s “a prospective, risk-adjusted comprehensive payment for delivery of comprehensive care. While a base payment covers practice expenses, a bonus payment is tied to specific patient- and cost-related measures.”  I don’t know what any of that means other than it will 100% fail.  He just let the hamster off one wheel and put it on another.

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Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  5 comments for “Ridiculous Study of the Week: Try My Better Hamster Wheel

  1. Christopher Rhody
    July 24, 2018 at 3:41 pm

    It doesn’t matter. Primary Care Doctors are dinosaurs. We will be gone soon, replaced by sleeker cheaper nurse practitioners and advanced practice nurses. This is why students learn medicine by algorithm and not the history of why. So learn a technical skill or be a miracle worker. Otherwise your only recourse is as the supervising physician of a gaggle of “practitioners” so the malpractice costs stay down. The movement of the rewards for medicine from Doctors to administrators is nearly complete. The Deathstar is here and we have no Luke Skywalker.

  2. bbneo
    July 18, 2018 at 4:44 pm
  3. CHRIS
    July 18, 2018 at 10:05 am

    My own personal experience with Medicaid is a little unusual since I am an RHC and I get reimbursed a ridiculously high rate for seeing Medicaid patients (a flat rate $130 per visit). I personally have tried to boost my medicaid census, so I would say that paying me more has influenced me to see more Medicaid patients although I have never tried to cherry-pick my patients by their insurance coverage (so even before I became an RHC I saw Medicaid patients and didn’t really pay much attention to what insurance they had until it came time to try to refer them somewhere or prescribe medication to them). Interestingly, my hospital has repeatedly asked me if I wish to go to an RVU based pay system and I have told them “no thanks, I think I will just stay on a cash basis”.

    Having said that, the person quoted in the article basically said “We used to give doctors very shitty reimbursement and we found that giving them slightly less shitty reimbursement didn’t motivate them to see these patients any more.”

  4. Rick M Singel
    July 18, 2018 at 7:50 am

    Really, my mind can’t even process the language these geniuses use to explain their theories. I am truly sick of it. Like first year law students, they try to sound smart by using big words.

  5. PW
    July 18, 2018 at 7:27 am

    The rats are winning the rat race.

Comments are closed.