Mushing Stuff Around a Dinner Plate: The Modern Approach to Health-Care Spending

I have always been a good eater. Sometimes, I have been a little too good. It’s one of the motivations for my fitness regimen since I have had my pudgy days and don’t want to return to them. If you are running a buffet or some other AYCE establishment (that is “all you can eat” for the normies), you might prefer I go somewhere else.

At some point in my childhood, I learned not all kids shared this trait. I was fascinated to hear that some came up with maneuvers to convince their parents that they had consumed enough to be allowed to depart the table. A classic was mushing unwanted food around the plate in strategic ways to make it seem less voluminous. Surely, I thought, that wouldn’t fool anyone.

Evidently, I was wrong. Either parents were snowed or they got fed up with watching the attempt and let their kids go rather than continue the tiresome charade. I have seen with ongoing disbelief that some folks continue to use similar tricks long after they grow up.

One of its applications is in playing with budgets. Health-care spending and other governmental outlets are particularly conducive. They are effectively bottomless wells with such bureaucratic complexity that few individuals can even see the entirety of your metaphorical dinner plate, much less keep track of where everything is on it.

Instead, they see tiny fractions of the big picture and often conclude that they know what is going on with spending. We in radiology commonly witness fits of outrage when someone, either personally known or on social media, shares an episode of going to the ER for a stubbed toe or the like and gets ahold of their bill or “explanation of benefits.” Thousands of bucks for an X-ray or some blood work? Obviously, this is the fault of greedy doctors!

The day may come when I will have become too jaded to try but to date, I will wade into the fray to point out that no radiologist reading such an image pockets thousands or even hundreds of bucks for the task. His or her liability for it may be in the millions, but its income value will likely be in the single digits (double if he or she is lucky).

Whoever has gotten their gums in an uproar over the inflated costs is still primed to blame a villain. The forum is not great for turning their heads to blaming the whole system. At best, I will be able to remove rads (if not doctors at large) from the bullseye. They can then point accusing fingers at hospital administrators and insurance companies.

Unfortunately, that leads a lot of them to conclude that the solution would be to give more control over to the government, which, in most ways, is the actual culprit. “Villain” is, however, too flattering a term for the role filled by politicians and regulators in all of this. Most of them aren’t hatching sinister, well-concocted plans here.

Instead, they are doing the adult (I use the term loosely) version of a kid mushing unwanted mashed potatoes and peas around a plate. In their version, the wasted food is health-care spending, and they are just playing at where the dollars are going.

There have been performative gestures toward adjusting the overall amount of stuff on the plate in the name of “budget neutrality” and “sustainable growth,” but I have yet to see anyone point at some part of the health-care system and declare it to be any more efficient or otherwise improved as a result of this.

Accordingly, the resources get pushed around the plate to make it seem like something is being done. Primary care folks get a little bump at expense of the specialists. Metrics for improvement are supposedly established to reward good outcomes, but their bankroll comes from siphoning away other portions of the health-care sphere.

Anybody who has been in the health-care space for a little while can tell you a bunch of ways this has failed to do any good and often inflicts harm. Dwelling in radiology since the beginning of the century, I have had a front-row seat to its impact on the imaging arena.

Things were already pretty far gone when I began residency. The attendings shared gentle lamentations of how the “golden days” of rads were gone, but it was still a good specialty. Radiology was one of a few remaining profit centers in a typical hospital. Most departments operated at a loss and administrators would use part of our surplus to keep others afloat.

Fast-forward years of CMS cuts and adjustments, and we weren’t such a wellspring. More and more imaging studies now operated at a loss, but the idea was that “advanced imaging” (CT, MRI, etc) still flowed in blank ink rather than red, and those modalities kept us viable.

Now let us look at the present day. Pure wRVU-based “per-click” values no longer cut it. Hospitals (or whoever else holds the purse strings in a particular venue) routinely have to add subsidies if they want to have sufficient rad coverage. Just like we used to do for other departments 20+ years ago, we are now being kept afloat by others.

But what others? In some instances, it is still effectively the rad department but now including a portion of the “technical component” reimbursement. Historically, unless you owned the gear and paid the techs yourself, that component was out of your hands.

Trying to dig a little deeper, I encountered other sources such as the “general operating revenue” at hospitals. That sounds good and nebulous, much like the mixed mush a kid pushes around his or her plate. It includes all sorts of things, including government grants that, one might reasonably guess, were more able to be funded after cutting physician reimbursement rates.

Not only does all of this obfuscation impair efficiency of the health-care beast, it creates a gazillion winners and losers, all of whom can proceed to argue and struggle against one another year after year. Not to be outdone, the politicians and regulators atop this heap can grandstand and pretend to fight one another like fake wrestlers from the WWE minus the steroids and flashy costumes.