doctor pay structure

[doctalaughs]

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They always are saying doctors should be paid based on outcomes... which is almost impossible to measure. However, we all know who the good doctors and bad ones are... it's easy for other physicians to tell. Right now doctors are paid to "churn" a lot of patients or do a lot of procedures, which is why healthcare is so expensive and ineffectual. I think doctors should be paid:

1. An annual base salary based on years of training, which can be up to 100% if you meet critera below:
- as long as you see X number of patients a day, which is based on a standard average number for that specialty
- X can be adjusted for you by an independent blinded panel of physicans in your specialty if you see a subset of patients that are more or less complex than usual. It would be easy to determine if a physician sees easier or harder cases by reading a sampling of their notes.

2. A bonus which can be up to 50% more based on a number of factors
- efficient care: you use less of society's money ordering expensive tests and procedures
- base knowledge: based on your board scores, specialty board scores, recerts and what program you trained at
- your patients like you: online based surveys they can fill out
- you work harder: you see more patients than X, up to a given reasonable number


Of course no system is perfect but right now you can be a CRAPPY doctor and get paid a lot cause you are a good businessman. You can be a great doctor but be paid poorly because you are a poor businessman... and that is just bad for a country in general where resources are not infinite and we all want good outcomes as an endpoint.

 

[Pinkertinkle]

Yeah but once you hand off that kinda power to some governing body it's a slippery slope to where they can pay you x dollars an hour, take it or leave it.

 

[EC3]

Simplified pay structure:

1) Set price.
2) Require payment before service.

 

[G'ville Nole]

Simplified pay structure:

1) Set price.
2) Require payment before service.

Ridiculous. Name me one area of the market where that approach is effective and helps to contain costs.

Oh wait, it works in ALL areas of the market!

Never mind.

 

[docB]

Right now doctors are paid to "churn" a lot of patients or do a lot of procedures, which is why healthcare is so expensive and ineffectual.

That is a grossly inaccurate statement and belies a significant amount of ignorance about medical economics. It even oversimplifies the point you are trying to make to such a degree that it is completely lost.

I can’t disagree more with these assertions. Each would create a number of perverse incentives and unintended consequences.

I think doctors should be paid:

1. An annual base salary based on years of training, which can be up to 100% if you meet critera below:

So now we will reward years of training above all else? That will be the death of primary care. Although this would create an incentive to expand all residencies to be as long as possible. If I create a 6 year EM program with a batch of 3 year fellowships attached I will guarantee my grads the opportunity to make the most money.

- as long as you see X number of patients a day, which is based on a standard average number for that specialty

This would incentivize docs to skimp on individual patients in order to meet their quota.

- X can be adjusted for you by an independent blinded panel of physicans in your specialty if you see a subset of patients that are more or less complex than usual. It would be easy to determine if a physician sees easier or harder cases by reading a sampling of their notes.

This would not be “easy.” Case review is always difficult, tedious and time consuming. Who will be doing this and how will we pay the reviewers?

2. A bonus which can be up to 50% more based on a number of factors
- efficient care: you use less of society's money ordering expensive tests and procedures

This just replaces your purported incentive to do too much with an incentive to do too little.

- base knowledge: based on your board scores, specialty board scores, recerts and what program you trained at

You’re going to base pay on board scores and where you trained? That’s a really bad idea. You’d ultimately be rewarding test taking ability. You would also be skewing the way applicants look at residencies. This type of system would punish people who want to do their residency in a particular geographic location rather than at a program that you will have designated as being one that allows greater pay.

Also I’m not sure how you would rate all the residencies out there. There’s a lot of controversy about what makes a quality program. One of the only things certain about ranking programs is that almost no one agrees on how it should be done.

- your patients like you: online based surveys they can fill out

So you would reward docs who are really nice regardless of quality. Patients are notoriously poor judges of whether or not they got good care based on what physician peers would agree is appropriate. They do mark doctors down for having accents, racial prejudices and having cultural mores that they don’t like.

- you work harder: you see more patients than X, up to a given reasonable number

Again you’re creating an incentive to meet a quota. That’s the car salesman’s approach to medicine.

 

[michaelrack]

They do mark doctors down for having accents, racial prejudices and having cultural mores that they don’t like.

.

They also mark down docs for not passing out benzo's and opioids like they were candy

 

[Toohotinvegas33]

Sounds like a great idea 👎 .....🙄

 

[doctalaughs]

That is a grossly inaccurate statement and belies a significant amount of ignorance about medical economics. It even oversimplifies the point you are trying to make to such a degree that it is completely lost.

I can’t disagree more with these assertions. Each would create a number of perverse incentives and unintended consequences.


So now we will reward years of training above all else? That will be the death of primary care. Although this would create an incentive to expand all residencies to be as long as possible. If I create a 6 year EM program with a batch of 3 year fellowships attached I will guarantee my grads the opportunity to make the most money.


This would incentivize docs to skimp on individual patients in order to meet their quota.


This would not be “easy.” Case review is always difficult, tedious and time consuming. Who will be doing this and how will we pay the reviewers?


This just replaces your purported incentive to do too much with an incentive to do too little.


You’re going to base pay on board scores and where you trained? That’s a really bad idea. You’d ultimately be rewarding test taking ability. You would also be skewing the way applicants look at residencies. This type of system would punish people who want to do their residency in a particular geographic location rather than at a program that you will have designated as being one that allows greater pay.

Also I’m not sure how you would rate all the residencies out there. There’s a lot of controversy about what makes a quality program. One of the only things certain about ranking programs is that almost no one agrees on how it should be done.


So you would reward docs who are really nice regardless of quality. Patients are notoriously poor judges of whether or not they got good care based on what physician peers would agree is appropriate. They do mark doctors down for having accents, racial prejudices and having cultural mores that they don’t like.



Again you’re creating an incentive to meet a quota. That’s the car salesman’s approach to medicine.

While you belittle my proposals you don't offer any of your own. I assert while these ideas are in no way perfect, they are better than the "perverse" incentives in place today.

Pay based on years of training - could be tailored to not reward excessive extra years. IE you get more for each year but it marginally so people don't do excessive fellowships. A neurosurgeon should get a bit more than a pediatrician to compensate for lost years of earning.

Pay dissociated from # of procedures/surgeries - don't pretend there aren't a LOT of unnecessary procedures going on. Plenty of "borderline" calls for cardiac caths, MRIs, CTs, spinal surgery etc. Doctors should be totally money-neutral when they make these decisions. Of course an interventional cardiologist is going to do a cath sometimes when it isn't necessary if they get 800 dollars for it; may not be due to intentional greed - it's just the culture and how they have been trained. Read Dr. Gawande's article on McAllen texas where they do 2x more caths on the same population as the neighboring county.

Pay based on training/scores/recerts - as I said before, right now pay has absolutely NOTHING to do with how good a doctor you are. I did not say pay would be totally based on program and scores - just a small component. Cause on AVERAGE a doc going to a better program with much higher scores will on AVERAGE be a better doc.

I don't feel like addressing the rest of your comments but if you think the system now is better for us as a nation, please tell me why.

 

[docB]

While you belittle my proposals you don't offer any of your own.

That’s true. You put your ideas up for comment. It’s not required that someone present alternatives just to voice differing opinions.

I assert while these ideas are in no way perfect, they are better than the "perverse" incentives in place today.

Pay based on years of training - could be tailored to not reward excessive extra years. IE you get more for each year but it marginally so people don't do excessive fellowships. A neurosurgeon should get a bit more than a pediatrician to compensate for lost years of earning.

Try to define your terms “excessive” and “a bit.” You should start to get an idea of how insanely complicated, contentious and divisive such a system would become. And again remember that you are just creating a different “perverse” incentive to push people away from primary care.

Pay dissociated from # of procedures/surgeries - don't pretend there aren't a LOT of unnecessary procedures going on. Plenty of "borderline" calls for cardiac caths, MRIs, CTs, spinal surgery etc. Doctors should be totally money-neutral when they make these decisions. Of course an interventional cardiologist is going to do a cath sometimes when it isn't necessary if they get 800 dollars for it; may not be due to intentional greed - it's just the culture and how they have been trained. Read Dr. Gawande's article on McAllen texas where they do 2x more caths on the same population as the neighboring county.

I don’t see a lot of unnecessary procedures happening. From the perspective of an ER doc I have trouble getting procedural specialists to do anything at all. It is in this argument that you are making your most glaring erroneous assumptions. Procedural specialists have patients referred to them from other doctors who thought that the patient needed their services. It is illegal for those referring doctors to make money from that referral. I don’t make any money from ordering CTs or MRIs or labs. And the docs that do bill for those services don’t have any role in my ordering those tests. The assertion that the system creates a huge incentive for unnecessary procedures stems from a misunderstanding about how the system works. It is a pretty pervasive misunderstanding. Obama was under the same misperception when he implied that a doctor had an incentive to let a diabetic get bad enough to require an amputation so he could charge for the procedure.

Pay based on training/scores/recerts - as I said before, right now pay has absolutely NOTHING to do with how good a doctor you are. I did not say pay would be totally based on program and scores - just a small component. Cause on AVERAGE a doc going to a better program with much higher scores will on AVERAGE be a better doc.

Wow! That’s a pretty bold statement. I don’t know how you would go about proving such a thing but I would hope you would before you link pay to testing and residency prestige. Would we be going on just the US News rankings or would there be some other list?

I don't feel like addressing the rest of your comments but if you think the system now is better for us as a nation, please tell me why.

I did. I think the current system is better than your plan for all of the aforementioned reasons, some of which you don’t feel like addressing.

As for an alternative I would argue that the most perverse incentive we have in American medicine is the medical malpractice crisis and the resultant defensive medicine. If you want to find the main factor that causes unnecessary procedures and diagnostics and just generally causes doctors to do more than their clinical experience tells them is required then you need look no further.

 

[Trifling Jester]

Pay dissociated from # of procedures/surgeries - don't pretend there aren't a LOT of unnecessary procedures going on. Plenty of "borderline" calls for cardiac caths, MRIs, CTs, spinal surgery etc. Doctors should be totally money-neutral when they make these decisions. Of course an interventional cardiologist is going to do a cath sometimes when it isn't necessary if they get 800 dollars for it; may not be due to intentional greed - it's just the culture and how they have been trained. Read Dr. Gawande's article on McAllen texas where they do 2x more caths on the same population as the neighboring county.

If you think you're seeing unnecessary procedures then you should report that doctor to the state medical board. If you haven't done that then you're F.O.S. You either lack the specialized expertise to make a judgment call that it's truly unnecessary, or you lack the intestinal fortitude to stand up for your ethical beliefs.

Pay based on training/scores/recerts - as I said before, right now pay has absolutely NOTHING to do with how good a doctor you are. I did not say pay would be totally based on program and scores - just a small component. Cause on AVERAGE a doc going to a better program with much higher scores will on AVERAGE be a better doc.

Show me the evidence that a doctor with higher board scores provides better medical care than a doctor with lower board scores.

Show me the evidence that a board-certified physician from one medical school provides better medical care than a board-certified physician from another medical school.

-The Trifling Jester

 

[doctalaughs]

Ug, lots of docs in here that would just defend the status quo blindly...

Well read Dr. Gawande's article- he's much more convincing than me:

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

In response to above:
1) I wholeheartedly agree with malpractice environment reform... even though there is good evidence it would represent modest healthcare savings at best... would save us a lot of headaches, stress and any savings is savings.

2) of course I know the ER doc doesn't get a dime for the MRI or CT he orders. But with the time pressures today, its easier to just refer or image the patient than try to deal with their problems... and when you refer to a specialist... well, you get specialist procedures. The incentives now are to
- refer quickly
- order imaging to cover your butt from lawsuits
- order a lot of low-yield tests
- do surgery if there is any question surgery is needed
- do everything in the ICU possible to keep people alive without much time or effort into discussing if it's what the family wants, or giving the patient a clear picture of prognosis

3) The sad truth is that we NEED to ration care eventually. We have infinitely expensive surgeries, procedures, imaging, diagnostics and drugs with limited resources. We can get some extra benefit by employing these technologies. Maybe we can cure someone's cancer for 5 million dollars or keep someone alive with a bad genetic disorder for 20 million dollars.... but we can't do that for everyone or we go bankrupt. Someone has to decide where to put our recources and we as physicians are failing at that... failing badly.

4) forget I even mentioned compensation based on merit. Of course there is no way to prove better scores and training program means better doc cause there is no way to measure how good a doctor is.

 

[psychbender]

2) of course I know the ER doc doesn't get a dime for the MRI or CT he orders. But with the time pressures today, its easier to just refer or image the patient than try to deal with their problems... and when you refer to a specialist... well, you get specialist procedures. The incentives now are to
- refer quickly
- order imaging to cover your butt from lawsuits
- order a lot of low-yield tests
- do surgery if there is any question surgery is needed
- do everything in the ICU possible to keep people alive without much time or effort into discussing if it's what the family wants, or giving the patient a clear picture of prognosis

Duder, have you even started medical school, or seen the inside of a hospital? Some of what you say (ordering CYA imaging) is fairly common, but comments with regards to ICU care are totally bogus. Its the patients and their families that are requesting the absurd care that they receive, not the doctors. I have had, or been part of, many family meetings, where we had very lengthy discussion regarding prognosis and treatment options. It is always the family that says "do everything," rather than the doctor just doing it all without consulting the family.

I agree, we need to ration care, we need to reform malpractice. You are very wrong, though, about incentives for procedures or referrals. Very, very few specialties do this. We are not just blindly defending the status quo, I'm not terribly fond of the status quo; it seems more that you are blinding defending the notions espoused by Gawande and others, and ignoring what those of us in residency or practice are telling you about how things actually work in most of the country.

Work with a FM doc, see how often they refer patients out. EM may do it more often, because it is not supposed to be their job to deal with chronic health maintenance issues. Images and 'low-yield' tests are ordered for CYA, not profit (the ordering docs are not the profiting docs in the vast majority of cases). If a surgeon thinks that an operation is needed, then there probably is some indication for it to be done. Would the patient be fine without an operation? Maybe, but do you want to be the surgeon that doesn't operate on that appy that later ruptures? Also, remember that billings and collections are two wildly different things, and that for many surgical procedures, the surgeon may get very little, with much of that eaten by overhead.

 

[Tigerz_Fan]

2) of course I know the ER doc doesn't get a dime for the MRI or CT he orders. But with the time pressures today, its easier to just refer or image the patient than try to deal with their problems... and when you refer to a specialist... well, you get specialist procedures. The incentives now are to
- refer quickly
- order imaging to cover your butt from lawsuits
- order a lot of low-yield tests
- do surgery if there is any question surgery is needed
- do everything in the ICU possible to keep people alive without much time or effort into discussing if it's what the family wants, or giving the patient a clear picture of prognosis

.

You have obviously never worked a day in the ICU. Several hours every day are spent in family discussions. Totally agree with psychbender. Many of the cases that are absurd are by the demands of family, not psycho ICU docs that keep patients alive just for kicks. Haven't you heard of an Ethics Committee? We utilize them fairly regularly.

 

[NotAProgDirector]

A fascinating discussion, that clearly demonstrates the problem. Everyone is trying to figure out who's to blame for skyrocketing health care costs. And the answer is obvious.

It's all of us.

The malpractice environment drives some testing excesses.

Patients have developed the attitude that medicine should fix everything, and cost nothing.

New tests/procedures/treatments are developed that are less invasive and risky. Although this is clearly a good thing, it leads to overuse. When taking out a gallbladder meant 3 weeks of major pain/recovery, patients and physicians thought twice about it. Now that lap chole's are the norm, GB's tend to get removed at the first sign of trouble. This is NOT suggesting that physicians are doing so to pad their wallets (although any physician paid fee-for-service will in fact make more money the more procedures they do). It's simply that increased medical resources, especially with less invasive procedures with less risk, tends to lead to more procedures. The question at hand is whether these increased procedures actually makes people better -- most research suggests that it doesn't.

This is also not to suggest that this is purely a surgical or proceduralist issue. PCP's are just as liable. I am salaried, so I am also supposedly protected from this problem. But not so -- my RVU's are measured each month. If they drop, my boss talks to me. I am being taught how to bill at higher levels -- "might as well get paid more for what you do" they tell me. I only get RVU;s for seeing patients in the office. Managing via the phone, web, or email gets me nothing. Many of my colleagues refuse tro answer emails at all, demand patients see them in the office for this reason. I have to keep my booking level >95%. If it drops, my office suggests I bring people back in more often.

The reimbursement system does influence us. Just like the argument that "drug reps coming to my office and giving me free food doesn't influence my practice" is bogus (for, why would reps do this if it didn't work?), we are each subtly influenced by the reimbursement system. We learn what gets us ahead (RVU/$) and what doesn't, and change practice patterns to match. I get paid about the same whether I see a really sick patient, or someone who really is fine. It really is in my best interest to see my routine, well controlled diabetics more frequently, as it's easier and I get paid just as much.

Physicians are the focal point of all of these forces. It all passes through us. Much of it we cannot control. But neither can we abdicate responsibility to others. The current system is unsustainable, and the status quo won't work for much longer. Our current system works well enough at present that most people don't feel the pain, but it will certainly get worse if we don't do something about it.

I honestly have no clear idea of what to do. We live in a capitalistic society, and hence we should assume that physicians will be driven by profit. If we continue with a fee-for-service system, physicians will continue to perform procedures / see patients frequently. Salarying all physicians (Mayo and CCF and others are held up of examples of this) takes the volume out of the equation -- however once salaried the incentive reverses and the goal becomes to do as little as possible -- why bother working hard when you don't get anything for it?

 

[docB]

Ug, lots of docs in here that would just defend the status quo blindly...

Well read Dr. Gawande's article- he's much more convincing than me:

http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande .

Here are my problems with Gawande’s stance. He is visiting the worst place in the nation for these problems and generalizing them across the board. He keeps referring to the quality of healthcare but it seems as though he’s referring to the system by which “Medicare ranks hospitals on twenty-five metrics of care.” That sounds like he’s talking about the Core Measures which is just a ridiculous set of hoops CMS has made us jump through over the past few years. I don’t know that I would credit it with effectively ranking anything other than bureaucratic stupidity.

In response to above:
1) I wholeheartedly agree with malpractice environment reform... even though there is good evidence it would represent modest healthcare savings at best... would save us a lot of headaches, stress and any savings is savings. .

I think med mal reform would save us a lot more than most of the current estimates predict. That’s because those estimates only assume that the defensive medicine that would go away is the really out of bounds stuff that falls outside the “standard of care.” I would argue that because our current “standard of care” evolved in the current med mal environment it itself is inherently defensive. Just look at how we deal with chest pain.

2) of course I know the ER doc doesn't get a dime for the MRI or CT he orders. But with the time pressures today, its easier to just refer or image the patient than try to deal with their problems... and when you refer to a specialist... well, you get specialist procedures. The incentives now are to
- refer quickly
- order imaging to cover your butt from lawsuits
- order a lot of low-yield tests
- do surgery if there is any question surgery is needed
- do everything in the ICU possible to keep people alive without much time or effort into discussing if it's what the family wants, or giving the patient a clear picture of prognosis.

But all of those issues are due to fear of lawsuit much more than greed.

3) The sad truth is that we NEED to ration care eventually. We have infinitely expensive surgeries, procedures, imaging, diagnostics and drugs with limited resources. We can get some extra benefit by employing these technologies. Maybe we can cure someone's cancer for 5 million dollars or keep someone alive with a bad genetic disorder for 20 million dollars.... but we can't do that for everyone or we go bankrupt. Someone has to decide where to put our recources and we as physicians are failing at that... failing badly.

That is all true.

 

[Faebinder]

They always are saying doctors should be paid based on outcomes... which is almost impossible to measure. However, we all know who the good doctors and bad ones are... it's easy for other physicians to tell. Right now doctors are paid to "churn" a lot of patients or do a lot of procedures, which is why healthcare is so expensive and ineffectual. I think doctors should be paid:

1. An annual base salary based on years of training, which can be up to 100% if you meet critera below:
- as long as you see X number of patients a day, which is based on a standard average number for that specialty
- X can be adjusted for you by an independent blinded panel of physicans in your specialty if you see a subset of patients that are more or less complex than usual. It would be easy to determine if a physician sees easier or harder cases by reading a sampling of their notes.

2. A bonus which can be up to 50% more based on a number of factors
- efficient care: you use less of society's money ordering expensive tests and procedures
- base knowledge: based on your board scores, specialty board scores, recerts and what program you trained at
- your patients like you: online based surveys they can fill out- you work harder: you see more patients than X, up to a given reasonable number


Of course no system is perfect but right now you can be a CRAPPY doctor and get paid a lot cause you are a good businessman. You can be a great doctor but be paid poorly because you are a poor businessman... and that is just bad for a country in general where resources are not infinite and we all want good outcomes as an endpoint.

VERY NAIVE!

Do you expect psychiatrists/ER docs to be liked by many of their patients (all the psychotics and manics would give us bad "surveys" for keeping them and all the druggies and malingerers would give us bad "surveys" for not giving them what they are craving).

Practice some medicine first them make the above naive list.

 

[doctalaughs]

I love comments like:
"Practice some medicine first them make the above naive list."
You have obviously never worked a day in the ICU.
"have you even started medical school, or seen the inside of a hospital?"

Look- feel free to disagree with me but I do know how things work, have had these conversations with families many times, and finished my residency. And yes, I have worked in an ICU, I suspect more years than some of you.

Some docs are good and take the time to explain prognosis well; others hold patient autonomy so highly that they fail to see they can influence families by painting the correct picture, which is an art. The palliative care docs are excellent at it but many other physicians are horrible. In the right situation it's enough to just say: "I'm sorry. Your mother/sister/father is dying. There isn't anything else we can do." You DON't need to offer dialysis or ocillator or anything crazy if it will only help temporarily.

Tell me you haven't seen:
1) a 90 year old flown in on flight-for-life for a procedure that really would be dumb to do on someone that age.
2) a terminal cancer patient kept alive on the vent for weeks
3) a drug with MARGINAL, maybe even DUBIOUS evidence for efficacy beyond the standard, costs a ton, but still prescribed.

Tell youself all you want that it's the "Crazy family" that wanted it. Truth is, there is a physician behind each of these decisions who approached the situation wrongly. If you don't offer it, the family can't decide on it.

Keep telling youself that your treatments and interventions are GOLD and completely NECESSARY and we shouldn't change at all. Well, healthcare costs are to the breaking point and physician salaries are going down. Where is all that extra money going? There is good evidence, even if you ignore it, that you cannot account for even 25% of it through insurance/drug companies and lawyers. Guess what- it's going to extra interventions. Call them necessary or unecessary- whatever you want. They have to be rationed one way or another and if we don't do it someone is going to do it FOR US.

 

[Tigerz_Fan]

I love comments like:
"Practice some medicine first them make the above naive list."
You have obviously never worked a day in the ICU.
"have you even started medical school, or seen the inside of a hospital?"

Look- feel free to disagree with me but I do know how things work, have had these conversations with families many times, and finished my residency. And yes, I have worked in an ICU, I suspect more years than some of you.

Some docs are good and take the time to explain prognosis well; others hold patient autonomy so highly that they fail to see they can influence families by painting the correct picture, which is an art. The palliative care docs are excellent at it but many other physicians are horrible. In the right situation it's enough to just say: "I'm sorry. Your mother/sister/father is dying. There isn't anything else we can do." You DON't need to offer dialysis or ocillator or anything crazy if it will only help temporarily.

Tell youself all you want that it's the "Crazy family" that wanted it. Truth is, there is a physician behind each of these decisions who approached the situation wrongly. If you don't offer it, the family can't decide on it.
.

Not to offend anyone, but can you please explain to me how you were accepted to University of Colorado for medical school 10/16/03 (by your previous posts), and have already completed residency and have had more years experience in the ICU than any of us?

There are many times that I do not want to continue the aggressive treatment on a certain patient. Unfortunately, it is the family that determines the patient's code status. If the family wants everything done, then until the Ethics Committee determines otherwise, they get everything done. Otherwise, I can promise you that a physician that goes against the family's wishes will end up in court pretty quickly.

 

[womp]

Look- feel free to disagree with me but I do know how things work, have had these conversations with families many times, and finished my residency. And yes, I have worked in an ICU, I suspect more years than some of you.

Not to offend anyone, but can you please explain to me how you were accepted to University of Colorado for medical school 10/16/03 (by your previous posts), and have already completed residency and have had more years experience in the ICU than any of us?

Ouch for the OP...

 

[AttyHubby]

Not to offend anyone, but can you please explain to me how you were accepted to University of Colorado for medical school 10/16/03 (by your previous posts), and have already completed residency and have had more years experience in the ICU than any of us?

Pwned so hard, love it

 

[sirus_virus]

They always are saying doctors should be paid based on outcomes... which is almost impossible to measure. However, we all know who the good doctors and bad ones are... it's easy for other physicians to tell. Right now doctors are paid to "churn" a lot of patients or do a lot of procedures, which is why healthcare is so expensive and ineffectual. I think doctors should be paid:

1. An annual base salary based on years of training, which can be up to 100% if you meet critera below:
- as long as you see X number of patients a day, which is based on a standard average number for that specialty
- X can be adjusted for you by an independent blinded panel of physicans in your specialty if you see a subset of patients that are more or less complex than usual. It would be easy to determine if a physician sees easier or harder cases by reading a sampling of their notes.

2. A bonus which can be up to 50% more based on a number of factors
- efficient care: you use less of society's money ordering expensive tests and procedures
- base knowledge: based on your board scores, specialty board scores, recerts and what program you trained at
- your patients like you: online based surveys they can fill out
- you work harder: you see more patients than X, up to a given reasonable number


Of course no system is perfect but right now you can be a CRAPPY doctor and get paid a lot cause you are a good businessman. You can be a great doctor but be paid poorly because you are a poor businessman... and that is just bad for a country in general where resources are not infinite and we all want good outcomes as an endpoint.

Even the soviets will laugh at this pay model.

 

[Arcan57]

OP = epic fail

Healthcare costs increase for a number of factors. Given that there are many areas of the country without limited/no access to certain specialties and the proliferation of midlevel providers in order to increase doctors' efficiency , it could be argued that docs "working too hard" is more a side effect than the cause of our current trouble.

A key component of spiraling costs is that the demand for healthcare is essentially infinite because little of the cost is born by the patient receiving the care. As the war on drugs has taught us, cracking down on the supply side of the equation is woefully ineffective if the demand continues to exist.


Now, you asked for an alternative proposal. In the Atlantic, there was an article regarding the creation of a national system of catastrophic health insurance in combination with mandatory health savings accounts. The HSAs would have a defined contribution based on income level, with subsidies going to those that have income levels less than x% of the federal poverty level. Unlike traditional HSAs, if you died with a positive balance the remainder was passed to your heirs. It deals with the problem of access for the working poor and indigent while at the same time shifting the responsibility for spending back onto the consumer.

 

[Tigerz_Fan]

Pwned so hard, love it

Anytime...........

 

[deleted4401]

The OP did display naivete, but there is a lot to be improved in the way we are paid. I do think it matters and pure FFS creates poor incentives. In my field, if I am unsure whether 5 treatments are better than 10 treatments, but I get paid for 10, there is an incentive to deliver 10 treatments.

The other thing about supply/demand, not only is it correct that patients don't bear the costs of the care they receive, but the physician decides what they should receive. In other words, the supply curve = demand curve. Instead of making an "X", we get just an upward sloping line. The more you feel the patient needs, the more they get.

I don't think doctors are just going for money. There is a fair amount of research on "target incomes", and most docs aim to reach this amount.

The general estimates of eliminating "defensive medicine" say that it will reduce overall costs by 1-3%. Not a whole lot in relative terms, but for an estimated $2 trillion/year spent on health care costs, that is potentially $20-60 billion a year that can be used as the subsidies for lower-income patients to pay their premiums.

I have no alternatives to offer. I really don't. I'm not sure how to fix all of this, but I don't think the way we get paid makes us think about how to be cost effective.

-S

 

[docB]

The general estimates of eliminating "defensive medicine" say that it will reduce overall costs by 1-3%. Not a whole lot in relative terms, but for an estimated $2 trillion/year spent on health care costs, that is potentially $20-60 billion a year that can be used as the subsidies for lower-income patients to pay their premiums.

Again I vehemently disagree with the data that says defensive medicine only adds up to 3%. That figure is derived from looking at diagnostics and procedures that are grossly outside the "standard of care" such as doing a CT Head on every sprained ankle to rule out occult brain injury. That data accepts as totally legitimate such practices as admitting every chest pain for "rule out MI" which is within the current "standard of care." It's important to remember that the standard of care for everything we treat has evolved under the med mal environment that has made them very conservative. If we eliminated the defensive incentive and developed standards that were less conservative we could save huge amounts of money.

 

[deleted4401]

I understand that you "vehemently disagree" with that figure, but without any references cited, I think it a safe assumption that we work with 1-3% as a general figure, with a maximum of 9%. The Kessler-McClellan study is the only study that estimated such a high estimate (5-9%), and its now widely discredited. The Rubin study estimates that $8 billion/year could be saved by aggressive malpractice reform, but that was in 1994, and it's safe to say we can double the number for the "modern era". The most cited number is the 3%, and that's based on the Harvard study, which gets us to about $60 billion in possible savings. I still think that's a good amount to work with, and I don't really see any other evidence that it's higher.

 

[michaelrack]

I which gets us to about $60 billion in possible savings. I still think that's a good amount to work with.

I remember when 60 billion was a lot of money

 

[porsche518]

If you don't offer it, the family can't decide on it.

I admire you bringing up a lot of these questions and arguing these points, regardless some the ad hominems. But they are the arguements of lay people of dont have a real understanding of the day to day of medicine. These are the type of questions that are asked of me whenever I discussing healthcare with my friends who are not in the field. I think we as physicians can learn a lot here because these are the views of a vast number of people of how medicine works and how we make our clinical decisions.

We done a horrible job in presenting our side of the arguement, and alleviating the situation.

As to your suggestion above of not presenting theraupeatic options to paitents or their family, is not what we do as doctors. Agreed there might be some situations where futile care is given because of the crazy family, and doctors have been at fault of not explaining things correctly. But from my experience the critical care doctors I have been around at multiple institutions have not only present all the options, but also let the family know what they think is appropriate. Most of the time that is enough.