Letters

Weighing the costs and benefits of family practice

To the Editor:

I agree with Dr. Gillette's assertion in "Why We're in the Mess We're In" [April 2002, page 27] that family practice remains an exciting specialty. I suspect the current stresses of caring for patients, while different, are no greater than the stress his father encountered in the 1930s. However, I question the assertion that the current cost-benefit ratio for family physicians is comparable to 70 years ago.

I suspect the degree of educational debt borne by modern physicians is greater than in the past. The average medical student graduates with a student loan balance of $140,000 or more. This staggering debt has diminishing deferral times in residency, cannot be meaningfully refinanced, is not tax deductible and usually cannot be eliminated by taking a loan-repayment job or by claiming bankruptcy. Loan payback programs are competitive and have received uncertain and unpredictable funding. Educational debt can't be gotten rid of by selling it as one might sell a car or EKG machine if the payments get too big. One can only work to pay it off over time.

People who didn't have the money just didn't go to medical school.

After paying educational debt each month, the money left over from the average new physician's salary does not leave much room for saving, paying down one's principal or living the lifestyle that most medical students assume they will enjoy. The limited personal budgets of many new physicians can be an unexpected shock. Physicians with large debt may avoid jobs that offer the potential for greater professional satisfaction if these jobs seem to carry an additional financial risk, such as start-up costs for private practice or uncertain loan repayment at government clinics. Likewise, there is pressure to forgo volunteer work, community involvement and personal time to provide such necessities as food, a car, a modest house and insurance. This unexpected pressure fosters the perception among new physicians that one must choose between paying one's educational debt in drudgery or enjoying life while courting financial disaster. This frightening choice, combined with difficult and low reimbursements and the lack of respect and understanding outlined so eloquently by Dr. Gillette, risks being the psychological nail in the coffin of job satisfaction. It is hard to combat stress at work when that work creates inescapable financial stress at home that could last for decades.

We are in an era of medicine where limited resources force us to employ cheaper therapies when possible in order to care for more patients. Just as we can no longer ignore the cost of our therapies, neither can we ignore the cost of our education and its impact on the physicians who deliver medicine on the front line.

Paul Heiderscheidt, MD
Huntington Beach, Calif.

To the Editor:

Having enjoyed "Why We're in the Mess We're In," I was taken by Dr. Gillette's closing statement about income for family physicians today being infinitely better than what his dad made in the 1930s. There is no doubt that 40 is greater than four - unless one applies the value of dollars in a particular time. Though I do not have figures from the 1930s, I do have testimony from practicing doctors today as to what they earned 42 years ago in 1960. Since physicians in the 1930s and 1960 operated under similar free market forces in a pre-managed care era, their incomes must have produced comparable purchase power.

A buck in 1960 not only got you and a date into a movie with popcorn, but you also got change back. Today, that's about $20 - or half of what a doctor may bill for an average encounter. A new, $1,600 station wagon represented 4 percent of a doctor's $39,000 annual earnings in 1960. Today's comparable minivan represents 22 percent of the average income for a family physician. Back then, a standard letter went across the continent for a few pennies; now it takes 37. A haircut that cost 50 cents now costs $10. Does the average physician make five to 20 times as much, "infinitely more," than his counterpart did in the 1930s?

Ironically, our predecessors got paid more when they could do less for their patients - at least when measured in terms of patient outcomes and longevity. They collected their full fees, whereas today 20 percent to 50 percent may be discounted. In 1960, if 10 percent of a physician's fees went toward overhead, it would be surprising. Today's family physician may realize as little as 40 percent of what is collected - not of what is charged!

Perhaps my understanding of "infinitely" differs minimally when it comes to the mess we're in. What is infinitely amazing is that as a profession, physicians have been able to withstand these blatant assaults and continue to be their patients' advocates.

Mark D. Schmidt, MD
Springboro, Ohio

Author's response:

Drs. Heiderscheidt and Schmidt make some interesting points, but their letters both contain errors of fact that undermine their validity. Dr. Heiderscheidt is correct in suspecting that "... the degree of educational debt borne by modern physicians is greater than in the past," but perhaps not for the reason he had in mind. Education loans as we know them today did not exist in 1960. My medical education was funded by my parents and my wife's salary as a school teacher and supplemented by income from "moonlighting" and summer jobs. Some of my classmates worked for a few years before starting medical school, living frugally and saving all they could. People who didn't have the money just didn't go to medical school.

Dr. Schmidt's letter contains many inaccuracies, beginning with his guesses about physician income in different decades. The Great Depression was on in the 1930s, and unemployment and poverty were widespread. Very few people had any kind of medical insurance. Conditions were better in the 1960s, although not comparable to what we enjoy today. Dr. Schmidt's figure of $1,600 as the cost of a station wagon in 1960 is only about half the actual price of a standard Ford or Chevrolet wagon that year. My practice overhead in the 1960s ran about 50 percent of receipts, not the 10 percent figure suggested by Dr. Schmidt. It's not true that physicians "collected their full fees" in pre-Medicare and pre-Medicaid America. The poor sometimes went without medical attention, but doctors gave significantly more flat-out "charity care" than they do today.

Robert Gillette, MD
Poland, Ohio

Pharmaceutical freebies

To the Editor:

While I normally enjoy Dr. Brown's Practice Diary, I was disappointed by his somewhat laissez-faire attitude toward gifts, goodies, perks and free dinners from pharmaceutical companies ["Drug Money," April 2002, page 55]. This attitude is all too common among physicians, who feel that they can't possibly be influenced and that they are easily able to sort the wheat from the chaff.

If only that were true. Studies repeatedly show that we don't know how much drugs cost, don't discuss drug costs with our patients often enough and too often reach for the most expensive drug when a less expensive alternative exists. Few physicians have the training to critically appraise studies or understand marketing ploys, such as the appeal to authority and the bandwagon appeal. The pharmaceutical industry spent $15.9 billion in 2000 on product promotion for one reason: It works. Spending on drugs increased by 17.9 percent last year, and the number of elderly seeking care in the Veterans Affairs health system has doubled in recent years, largely because they can no longer afford their medications. Patients choosing between an expensive proton pump inhibitor (PPI) and an anti-hypertensive may forgo the latter, since taking the former relieves symptoms and has a more immediate benefit.

Dr. Brown stated that he heard a lecture sponsored by Merck one month and then heard the same speaker at a Pfizer event several months later talking about a competing product. He says, tongue-in-cheek, that he considers this evidence that the drugs are probably equivalent. What we won't hear about at these dinners, though, is equally effective generic alternatives. At these dinners, we'll hear about the next generation of PPIs, but not ranitidine (which studies show is equally effective for half of long-term PPI users), and about an expensive new calcium channel blocker, but not hydrochlorothiazide or atenolol (which are both proven better at reducing mortality in hypertensive patients).

Dr. Brown also feels that drug cabinets are a useful resource for his patients. While I admit that they can occasionally be helpful, we are too often seduced by the samples into starting a patient on a new, expensive drug when an older alternative would be just as effective. Did seven free days of a new, expensive PPI really help a patient who could have been successfully treated with generic ranitidine for the next 20 years?

Our patients trust us to make decisions for their care based on the best available evidence, our clinical experience and our knowledge of their values and resources. Our integrity as a discipline is at stake if we don't stop kidding ourselves about these free lunches.

Mark Ebell, MD, MS
Athens, Ga.

Author's response:

Unfortunately, there are hardly any inexpensive drugs anymore. When I first started out in this business, no drug cost more than a dollar apiece. Now, it's hard to find one that costs less, with $2 to $3 a pill being the norm. Even generics can cost up to 70 percent of the brand-name price, especially if a medicine has just gone off patent. Atenolol is cheap, as are most diuretics, but not everyone can take them. Many patients need the newer drugs.

My local pharmacist tells me 91 percent of his customers get third-party help with their medications. In California, patients on Medicare are charged Medicaid drug prices. In addition, pharmaceutical companies have begun patient-in-need programs and offer discount coupons. Most patients have small co-pays to fill 30-day prescriptions, with the cost differential between generic and brand names being relatively minor. The situation isn't hopeless.

Although it would be ideal to only prescribe generics, sometimes the best-available evidence calls for a brand-name drug. For the 9 percent of my patients with no financial relief, I'm glad to have my drug closet as a resource and appreciative of the reps who fill it. Since I occasionally enjoy socializing with them, my conundrum is this: Can I retain the integrity of my discipline by paying for my own lunch, or must I additionally banish drug reps and their samples from my premises?

Sanford J. Brown, MD
Mendocino, Calif.

Corrections

In the FPM article "How to Get All the 99214s You Deserve" (October 2001, page 43), Emily Hill, PA-C, wrote that under the 1995 documentation guidelines an expanded problem focused exam involves two to four organ systems and a detailed exam involves five to seven organ systems. She also implied that the "3+ chronic disease" rule, which defines the extended history of the present illness (HPI) as four or more elements of the HPI or the status of three or more chronic conditions, can be used under either the 1995 or 1997 versions of the guidelines. Ms. Hill based her statements on an earlier FPM article, "Important Changes in the Documentation Guidelines" (February 1996, page 50), which reported statements made by (then) HCFA staff in a public forum that the 1995 guidelines would be modified to incorporate these changes.

Unfortunately, HCFA (now the Centers for Medicare & Medicaid Services or CMS) never incorporated the changes, and a CMS staff member recently told us that no such change is in the works. Consequently, the 1995 version of the documentation guidelines makes no distinction between expanded problem focused and detailed exams in terms of organ systems/body areas; each may involve two to seven. The only distinction is that an expanded problem focused exam is "limited" and a detailed exam is "extended." The 1995 guidelines also do not incorporate the "3+ chronic disease" rule in the definition of HPI.

WE WANT TO HEAR FROM YOU

Send your comments to fpmedit@aafp.org. Submission of a letter will be construed as granting AAFP permission to publish the letter in any of its publications in any form. We cannot respond to all letters we receive. Those chosen for publication will be edited for length and style.

Coding educators and consultants including Ms. Hill continue to teach and use the 1995 guidelines, making the distinction between expanded problem focused exams and detailed exams and using the definition of extended HPI that CMS staff described publicly in 1996. While there is a risk to following this unpublished advice, that risk is probably minimal given that the level of service may be justified on the basis of factors other than the exam and the HPI portion of the history and given the small percentage of claims that CMS actually reviews. In a worst-case scenario, CMS might downcode your claim by one level and ask you to refund the difference between what you were originally paid for the claim and the reimbursement amount for the lower level of service.

A reference was inadvertently omitted from the article "Achieving a More Minority-Friendly Practice" [June 2002, page 39]. The article should have cited the following as the source of the Cultural Competence Continuum: Cross TL, Bazron BJ, Dennis KW, Isaacs MR. Towards a Culturally Competent System of Care: Vol. 1. Washington, DC: Georgetown University, 1989.

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