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Specialty Care Providers

Specialty Care physicians, like PCP’s, are generally paid by the visit or by the procedure. The difference is that they’re paid MUCH better than PCP’s; often 2-5x or more. They can only get to become specialty physicians if they’re really good at what they do, and their income reinforces how society as a whole values them. After all, they routinely perform life saving or life changing services.

It’s in the specialty physician’s self interest to perform as many of their services as they can. Not only are they paid more by doing more, but – and this is really important – they generally get better by doing more. It’s a simple function of the more they practice, the better they get.

Specialty Care physicians interact with PCP’s when they get patient referrals. PCP’s usually refer to the specialists they know and respect, so this is generally perceived to be a win/win by both parties. More patients are always better for the specialist, and handing off a patient to a trusted specialist is part of the PCP’s role.

Specialty Care physicians obviously treat patients, and usually treat them well. Where interests can conflict is when the patient doesn’t have clear and complete information about all the options available in their circumstances, including the expected benefits to them personally and all inherent risks. Too often, there is a bias within the entire culture – patients, PCP’s, and specialists – toward aggressive procedures before a balanced review of less invasive options takes place. This is reinforced by an overemphasis of potential benefits and an under emphasis on risks during the informed consent process.  In the case of many cardiac and orthopedic surgical procedures, for example, there is little or no comparative effectiveness data demonstrating better outcomes from surgical procedures as opposed to outcomes from medical management.  The conflict of interest potential grows significantly when the speciality physician has a deep financial interest.  Historically this came primarily from the fee for service payment model, which inherently motivates a bias to aggressive (and profitable) procedures.  Lately it’s gotten worse as some surgeons have developed ownership interests in the distributorships that sit between medical device manufacturers and hospitals.  This prompted an investigation by a Senate Finance Committee, and among their findings, they concluded that these surgeons performed some procedures nearly twice as often as other surgeons that did not have ownership interests.  The findings prompted an OIG fraud alert.

And the human element can’t be ignored. As a specialty physician who has sharpened their skills for a decade or more, and has had many grateful patients, and has earned the respect of their peers, and is earning a very good living, is it any wonder that every referral doesn’t look like a nail to their very well honed hammer?

“When the healthy pursuit of self-interest and self-realization turns into self-absorption, other people can lose their intrinsic value in our eyes and become mere means to the fulfillment of our needs and desires.”

M. Forni, The Civility Solution

Specialty Care physicians interact with insurers, but they have much more leverage in negotiating their fee schedules than PCP’s. Increased utilization rates and advances in technology have resulted in a sharp increase in the expenses associated with specialty care; specialists perceive this as a win, since their income increases. Insurers consider this neutral or a win, since they either limit coverage of new techniques or increase premiums the next year to off set their increased costs and protect their profit margins.

Specialty Care physicians can either be employed by, have privileges at, or have a contract with local hospitals.   These are usually perceived by both parties as win/win relationships, especially when the specialists have good individual reputations or when their relationship with the hospital allows the hospital to offer desirable ‘units’ of care (such as specialized cardiac procedures).

The professional associations for specialty care physicians are well organized and have fairly active (and historically successful) lobbying efforts on capital hill, in an effort to influence present and future legislation in a direction favorable to them.

 

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