What Doctors Get Paid to Do

© Imelda Maurer, cdp January 28, 2009

Jerald Winakur and Dennis McCullough are physicians practicing in different parts of the country but with much in common. They are both geriatricians, each is married to a poet (!) and they are each authors of recently published books emanating from their life experiences in geriatric medicine.

Both men point to the same serious flaws in our healthcare system. One is the reimbursement system which is heavily skewed to procedures rather than what Dr. Winakur calls “cognitive” services. The latter includes taking adequate time to examine a patient,to listen and to watch his/her body language as s/he answers routine questions. We are all familiar with the first visit to a physician which includes the two-to-three page check list we are given to complete in the waiting room: questions about our personal and family medical history and of our daily habits (healthy or unhealthy!). Dr. Winakur chooses to take the time to ask these questions directly of the patient in the examining room, precisely, he says, because of what he learns through the patient's body language, the tone of voice, the hesitation, etc. What a man!

Cognitive services also include a careful review of medications, close monitoring and appropriate adjustments if called for. McCullough refers to this as “taking time for listening and understanding” As a result of how Medicare and private insurance companies reimburse medical services, too many patients are peremptorily “shunted off for various kind of expensive but ‘covered’ technical testing or quickly put on medication based on ever quickening decisions and standardized protocol. Pressures for efficiency and reimbursement plans skewed toward technological interventions routinely overrule more deeply caring and thoughtful responses to individual need.”

Winakur explains in more depth how reimbursement schedules are established. The American Medical Association has much to say about it, but the entire operation is very secretive with physicians such as Winakur and McCullough having little or no voice in arguing the the rightrful place of cognitive skills in the reimbursement schema.

One of the reasons I have heard given over the years as to why there is such a dearth of geriatricians in our country has been that they are not well paid. Now I understand why. Good medical practice for elders may not call for every single test or procedure in the book. (This is not to condone the ageism that is sometime seen when physicians neglect appropriate procedures solely on the basis of a patient’s age.)

Dr. Winakur began his practice as a board-certified internist. He became a geriatrician, he writes, “. . .because my patients and I have grown old together.” (Don’t you love it!) And ‘to keep up with them,’ he writes, I “continued to study the latest developments in clinical geriatrics,” and passed board examinations to become certified with “added qualifications in geriatrics.” Clearly, he’s not in it just for the money. What a man!

There are many good geriatricians out there. Geriatricians are specially trained to care for persons sixty years and older. I encourage everyone so blessed with years to seek one out as their primary care provider. Why a geriatrician at our age over a family practitioner or an internist? The next blog entry!

Perhaps our new President who has already heralded such hopeful signs of change, can help improve our healthcare system with help from an active, engaged public

The books referred to here are these:
Memory Lessons by Jerald Winakur
My Mother, Your Mother by Dennis McCullough