• Time sometimes does equal money

    I am so swamped with stuff right now, I can’t believe I’m taking time to blog. But I simply can’t let this go.

    One of the most frustrating parts of the health care reform mess was the obsession with death panels. It was the bizarre way in which private conversations between doctors and their patients was twisted into government deciding who would live and who would die. I think I’ve already made my point clear on how I feel about end-of-life care. But Avik Roy has a post up on how “Obamacare” would interfere in this process.

    Let’s be clear. What reform was advocating was that physicians get reimbursed for spending time with patients to have this discussion. But Avik writes:

    A provision in Obamacare was to provide government funding for doctors to have end-of-life discussions with their patients; to Gawande’s dismay, “it was deemed funding for ‘death panels’ and stripped out of the legislation.” The obvious question doesn’t seem to occur to him: Why do we need a government program to pay doctors to have thoughtful conversations about their patients’ eschatological desires — something they should be doing already, and that doesn’t cost a dime?

    Anytime someone writes about something doctors should be doing “that doesn’t cost a dime”, I think they are missing a fundamental point in the practice of medicine.  It’s the TIME that costs MONEY.  Often, when I see children for well care visits, other than a physical exam, the only thing I am giving is my time.  One of the major complaints of reimbursement is that we only pay more for “stuff”.  If I do more lab tests, I get paid more.  If I do more procedures, I get paid more.  But if I sit and talk with my patients, or counsel them, I often can’t bill for that.  I can’t get paid.  It’s a perverse incentive that not only increases unnecessary care and potentially increases harm, it devalues many real things that physicians do every day.

    And if you tell me, and all other physicians, that they should only get paid for stuff, and not for other things that actually do good but only involve listening and talking, well then things are only going to get worse.

    The reason we should pay physicians to do this is because we need to pay physicians to practice medicine.  Sometimes that involves only listening and talking.  Why do we need government programs to pay for this?  Because government programs provide the insurance for everyone over the age of 65 and therefore the vast majority of people discussing end-of-life planning.

    If you think Medicare equals “state run medicine”, then say so and actively campaign to get rid of it.

    If you think doctors shouldn’t be having discussions with their patients about end-of-life planning, then say so and fight to have that stopped.

    If you think doctors should work for free and that what they do in their office should not be reimbursed unless they are doing a procedure or test,  then say so, and get ready for all primary care practitioners to quit.

    But if you accept (happily or unhappily) that Medicare isn’t going anywhere, that private and personal discussions between patients and physicians about end-of-life planning are valuable, and that doctors should be paid for their time, then please explain to me why it’s evil for Medicare to reimburse doctors for that.

    UPDATE: Corrected a few typos.

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