Health Care Health Care Reform

The conflict of declining reimbursement…

Conflicted am I on reading of the strategy of a group of South Miami cardiologists who have written their patients complaining of the cuts to reimbursement, primarily cuts in imaging procedures.  A tension emerges from within upon reading the following quote from a “healthcare expert.”

“I’m not at all sympathetic with the cardiologists,” said Robert Berenson, a doctor who was once in charge of Medicare payment policy and now is a fellow with the Urban Institute. “Studies show they make well over $400,000 a year” — more than twice what a family practice physician earns.

This proclamation of overpayment emanates from an Urban Institute doctor.  In other words, a “think tank” doctor who toils in a cubicle with a computer and coffee mug rather than a lead apron and real lives changed if the burn gets too hot or stent placement off by a few millimeters.

On the other bipole is the patient who sees me for his defibrillator follow-up, but gets his general cardiac care in his hometown outside of the city.  He is free of symptoms since the heart attack and bypass surgery 6 years ago.  He is active, thin and compliant with the regimen of life prolonging medicines including statins, aspirin, beta blocker and ACE inhibitors.  And he asks me, the electrophysiolgist,  “Doc, is it really necessary for me to have a cardiolite (nuclear) stress test and echocardiogram every year?”

Yes, a perfectly stable non-diabetic patient without symptoms who is on all the right medicines is getting 1200 dollars of surveillance testing every year for the past 6 years.  As any master of the obvious would predict the tests consistently reveal an old scar from a previous heart attack.  For the record, a cardilolite stress test has the equivalent radiation exposure of nearly 10,000 chest xrays (CXR=0.06 mrem, Cardiolite=585 mrem).

The uncynical might suggest the cardiologist ordering these yearly tests is simply doing so for benevolent and cautious motives, but surely, the historically generous reimbursement of imaging has a role in decision making.  One has to ask whether ownership of the nuclear camera influences the decision to order these yearly exams.

Herein lies the conflict. The heart business is hard.   Electrophysiology private practice began at age 31 after eleven years of post graduate training and a living is earned adjacent to a fluoro unit with a lead apron and a catheter burning inside the beating heart.  The interventionalists or “squishers” who open blockages and reverse heart attacks do so within ninety minutes regardless of the clock face.

So, the blood heats when a “think tank” doctor opines on how much cardiologists are worth.  But yet, like the bad boy in elementary school whose misbehavior cost the entire class recess, the cardiologist who games the system hurts the entire profession.

One can see both sides of the coin.


2 replies on “The conflict of declining reimbursement…”

Well said.

One other area I would add to your discussion: the public's perception of our ability to "predict" heart attacks with these tests, thanks to institutional marketing efforts. While we might know better, patients insistence can influence the tests ordered or drugs dispensed as well. One only has to look to the pharmaceutical industry and its ability to leverage this psychology well with their direct-to-consumer ad campaigns.



Agreed. As a local bike racer, there are many in the fitness community who seek me out to get a stress test so as to prevent a heart attack while training. Or, they know of someone in the community who has suffered a catastrophic cardiac event.

The concept of stress tests not predicting heart attacks (Dr E Williams explained to me initially many years ago) is so difficult to effectively communicate. That a asymptomatic 20% lesion undetectable by an 850$ nuclear test is more likely to cause an event than the detectable 75% lesion is often met with a stare of disbelief. The inflammatory effects on the endothelium is also an elusive concept to explain.

So what do I do asks the Type A lawyer triathlete? I respond, eat well, sleep well, do not overtrain, lower your LDL etc etc. The response: Really, that is it? No test to predict an event.or as an obvious manifestation of advertising, the question, should I take Plavix?


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