How should pathologist pay be changed?

[pathstudent]

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Saw this in the Journal this morning.

http://online.wsj.com/article/SB10001424127887324021104578553793173806004.html?mod=hp_jrmodule

Pretty much across the board the experts think we should be paid for results and not for amount of work (so called value over volume). One expert said that the orthopedic surgeon should be paid based on how the patient is performing and how satisified the patient is six months after the operation.

That seemed a little silly to me. If your toilet breaks, you call the plumber and pay him once he is done. You don't pay him after six months if you are still happy with the flush.

But in any case I see the point of value over volume when it comes to primary care docs and other heavy clinic based specialties. But how would pathologists be reimbursed in this new system? Let's say a patient gets BCR-ABL positive ALL. I do the bone marrow, order the anciallary studies, do the micro and then put it all together. If I am going to be reimbursed on outcomes, how is this patient going to have a good outcome? How can you measure the quality of life of someone who will be aggressively treated and almost certainly die in a year or so? Or reading GI biopsies, how does someone have a good outcome after having their tubular adenoma signed out?

My point is that in pathology we have no real control about what happens to our "patients".

Moreover in pathology shouldn't someone that does twice as much work get paid twice as much or at least more due to the value of his volume?

I propose that pathologists should continue to get fee for service but with decreased reimbursement if our cases don't have essential information to better treat the patient.

 

[2121115]

I propose that pathologists should continue to get fee for service but with decreased reimbursement if our cases don't have essential information to better treat the patient.

Actually, something like this is what is being talked about for pathology (maybe radiology too).

 

[2121115]

Saw this in the Journal this morning.

http://online.wsj.com/article/SB10001424127887324021104578553793173806004.html?mod=hp_jrmodule

Pretty much across the board the experts think we should be paid for results and not for amount of work (so called value over volume).

All of those suggestions are essentially pipe dreams. They sound good, but in practical terms how would you accomplish any of it? Make surgeons, internists, and anesthesiologists fight each other for pieces of a bundled payment? Yeah right.

 

[Silent Cool]

I read the article and all I could think was, "All of this would be preventable if the gov't got out of medicine."

Makes me sick.

 

[thebouque]

I read the article and all I could think was, "All of this would be preventable if the gov't got out of medicine."

Makes me sick.

The free market isn't much better. You eventually need a regulating body. The gvt has its flaws but what else could be significantly better?

 

[pathstudent]

The free market isn't much better. You eventually need a regulating body. The gvt has its flaws but what else could be significantly better?

I enjoyed the comments to the article. Very insightful and some very funny

Why aren't all professions reimbursed based on quality over quantity. Why don't we have "experts" decide how plumbers, electricians, landscapers, architects, runway models, and interior decorators be paid?

I think you can argue that volume and value are intertwined. The more surgeries a surgeon has done, the more likely the patient has a better outcome. More volume equals more value.

 

[thebouque]

I enjoyed the comments to the article. Very insightful and some very funny

Why aren't all professions reimbursed based on quality over quantity. Why don't we have "experts" decide how plumbers, electricians, landscapers, architects, runway models, and interior decorators be paid?

I think you can argue that volume and value are intertwined. The more surgeries a surgeon has done, the more likely the patient has a better outcome. More volume equals more value.

It's actually quite simple. Plumbers, electricians etc have a legal obligation of results. However, physicians have a legal obligation of means only, not results. A physician that deals with more complex problems is going to have worse outcomes. Should he get paid less ?

 

[icpshootyz]

It's actually quite simple. Plumbers, electricians etc have a legal obligation of results. However, physicians have a legal obligation of means only, not results. A physician that deals with more complex problems is going to have worse outcomes. Should he get paid less ?

True, but his outcomes should be compared to the standard of care outcomes for his care or procedure, not a different field. Say you do CABG surgery and another surgeon removes appendices. The CABG patients are going to have worse outcomes, sure. But, if your CABG outcomes are better than the expected standard of care, you receive more pay. If they're worse, you get less. Obviously the heart surgeon shouldn't be directly compared to a pathologist or a pediatrician for outcomes. I'm not quite sure how they decide what each field is worth, so who knows.

 

[pathstudent]

It's actually quite simple. Plumbers, electricians etc have a legal obligation of results. However, physicians have a legal obligation of means only, not results. A physician that deals with more complex problems is going to have worse outcomes. Should he get paid less ?

I disagree. I think I have a legal obligation of results. If someone shows me a slide of a breast cancer, I can't say, "I don't know what it is but I looked at it and thought about it so pay me."

 

[KCShaw]

We need another industry shell surrounding us and costing the system more money to produce no better outcomes on the whole, while blaming physicians for the increasing costs, and decreasing their reimbursements, while medical education "costs" continue to balloon, ultimately leading off a cliff where applicants finally realize the cost/return ratio is no longer in their favor even by the end of a normal retirement age and cease to enter medicine?

Really, "awarding valued physician behaviors" sounds like giving them a chocolate for not peeing on the floor -- I have flashes of scenes from 'Big Bang Theory' and maybe some dog whisperer show. Sorry, I just don't think that flies any better than comparing outcomes of a rural physician doing the best they can with limited resources and patients who struggle to understand and/or just refuse to follow directions or otherwise help themselves, with someone at a large urban tertiary facility with a well educated patient population motivated to help the physician help them. Want to start scaling outcome measures by something like population age, education, economic status.. what else? All those determinations cost money just to make the decision, not to mention administrate making it all happen -- but for what, exactly?

 

[MOHS_01]

It's actually quite simple. Plumbers, electricians etc have a legal obligation of results. However, physicians have a legal obligation of means only, not results. A physician that deals with more complex problems is going to have worse outcomes. Should he get paid less ?

Nothing is quite simple once you dig into it a little....

True, but his outcomes should be compared to the standard of care outcomes for his care or procedure, not a different field. Say you do CABG surgery and another surgeon removes appendices. The CABG patients are going to have worse outcomes, sure. But, if your CABG outcomes are better than the expected standard of care, you receive more pay. If they're worse, you get less. Obviously the heart surgeon shouldn't be directly compared to a pathologist or a pediatrician for outcomes. I'm not quite sure how they decide what each field is worth, so who knows.

Therein lies the problem -- it is quite difficult, if not impossible, to assign appropriate peer groups for valid comparisons for the folks involved in direct patient care. Even within any given practice there could be a difference in the population served... and the other half of that equation (value, a function of cost and quality) is equally vexing as quality metrics are wholly absent for much of medicine and arguably insufficient for the rest. If we cannot so much as agree upon, much less define, what is good/better/best, how can we stratify docs in accordance to their chosen practices?

The next thing to think about is the incentive system that this provides. Every proposed system has one, and this is no different. With this proposed system, it is rather simple and easy -- avoid the sick and supratentorially challenged, get your "good" result numbers up, collect a premium for services rendered. Don't deal with those more likely to have complications or lesser outcomes. Live in an area where you do not have to deal with significant ignorance and non-compliance.

Not exactly an ideal incentive structure.

We need another industry shell surrounding us and costing the system more money to produce no better outcomes on the whole, while blaming physicians for the increasing costs, and decreasing their reimbursements, while medical education "costs" continue to balloon, ultimately leading off a cliff where applicants finally realize the cost/return ratio is no longer in their favor even by the end of a normal retirement age and cease to enter medicine?

For many fields in medicine this is already the case. I'm not so certain that most applicants place that level of thought into the decision making process, however, and in economic downturns especially medicine is a highly sought after gig. I'm afraid that will remain the case as long as the greater economy is engaged in a race to the bottom...

Really, "awarding valued physician behaviors" sounds like giving them a chocolate for not peeing on the floor -- I have flashes of scenes from 'Big Bang Theory' and maybe some dog whisperer show. Sorry, I just don't think that flies any better than comparing outcomes of a rural physician doing the best they can with limited resources and patients who struggle to understand and/or just refuse to follow directions or otherwise help themselves, with someone at a large urban tertiary facility with a well educated patient population motivated to help the physician help them. Want to start scaling outcome measures by something like population age, education, economic status.. what else? All those determinations cost money just to make the decision, not to mention administrate making it all happen -- but for what, exactly?

Exactly.

 

[2121115]

A single payor system is inevitable, eventually. European-style. Sure it has flaws, but that is what patients want, and the waiting times (or whatever other disadvantages) aren't as big a deal to them as cost. Period. Americans want cheaper health care and they will have it - and we will still have statistically worse outcomes even then, but at least it will be cheap.

 

[member0007]

A single payor system is inevitable, eventually. European-style. Sure it has flaws, but that is what patients want, and the waiting times (or whatever other disadvantages) aren't as big a deal to them as cost. Period. Americans want cheaper health care and they will have it - and we will still have statistically worse outcomes even then, but at least it will be cheap.

So true.

 

[jp123ok]

So true.

I'm not so sure that Americans will be willing to put up with outcomes like this:

http://www.theage.com.au/victoria/hospital-woes-hit-ambulance-services-hard-20130709-2pnbn.html

 

[WEBB PINKERTON]

Hospitals are now getting into the insurance business. Eventually they will control everything. They will force patients into their systems. Each state will have one or two "systems".

 

[rollwithit]

Doubled.

 

[path24]

Each state will have one or two "systems".

Strongly agree. Its coming. The question is how many years will it take? All of the hospitals in my area are part of "systems'...now the systems will start taking each other out. Consolidate path services...fewer pathologists needed. Bigger oversupply in the future.

 

[LADoc00]

Who is John Galt?

 

[yaah]

If you base pay too much on outcomes then certain doctors will start cherry picking the healthiest patients (already happening) so that they can get the healthy bonuses and such despite not really doing anything to earn it. And others will get stuck with the non-compliant, multiple medical problem, drug addicted individuals. I dislike these theories that someone bundling payments and paying for "quality" is going to be some sort of magic bullet. It isn't. Certain practices will seem more successful because they are able to attract the best patients. They will also do most of the routine, noncomplicated stuff. Meanwhile there will still have to be safety nets for complications and problem patients. I am hugely skeptical.

Ultimately the only ways that we are going to succeed at cutting health care costs are some or all of the following:
1) Increasing patient payments (higher deductibles, etc)
2) Decreasing payments to physicians and hospitals
3) Better technology making certain things cheaper or more efficient
4) Rationing.

Of these, #1 is starting to happen some places and having some effect. #2 is inevitable. #3 is a long range solution but since newer technologies keep developing it doesn't really have much effect.

#4 is political suicide but may end up reality at some point. If it does become reality, it is only going to become reality for those without political power (mostly the poor).

All this talk about "quality" is just a way to shift payments around and take them away from physicians and get more in the hands of administrators and hospital systems.

 

[Silent Cool]

Strongly agree. Its coming. The question is how many years will it take? All of the hospitals in my area are part of "systems'...now the systems will start taking each other out. Consolidate path services...fewer pathologists needed. Bigger oversupply in the future.

This reminds me of an article I read recently about a guy from Sweden who lamented the fact that Obamacare is taking us toward the Swedish model:

http://mises.org/daily/6476/The-Truth-About-SwedenCare

 

[deleted314957]

This reminds me of an article I read recently about a guy from Sweden who lamented the fact that Obamacare is taking us toward the Swedish model:

http://mises.org/daily/6476/The-Truth-About-SwedenCare

SWEDISH MODELS!! SHI*! and I just retired.

 

[LADoc00]

SWEDISH MODELS!! SHI*! and I just retired.

I would love to retire you lucking SOB. I hope you are healthy and live another 30+ years of bliss.

There are so few actually fully retired pathologists that I know, each one is essentially a legend around here.

 

[Silent Cool]

I would love to retire you lucking SOB. I hope you are healthy and live another 30+ years of bliss.

There are so few actually fully retired pathologists that I know, each one is essentially a legend around here.

I remember the quote from Kill Bill, "The number one cause of death is retirement."

 

[yaah]

There are so few actually fully retired pathologists that I know, each one is essentially a legend around here.

I don't understand this - there are tons of retired pathologists here. Our group has I think 6 or 7 still-living retirees. Almost every group I know in my area has had at least one retirement in the past 5 years. There are a lot of them who retire and then still do something minor, like teaching or something. But there isn't a mass population of 75 year olds manning the labs around here.

 

[LADoc00]

I don't understand this - there are tons of retired pathologists here. Our group has I think 6 or 7 still-living retirees. Almost every group I know in my area has had at least one retirement in the past 5 years. There are a lot of them who retire and then still do something minor, like teaching or something. But there isn't a mass population of 75 year olds manning the labs around here.

There is here for sure. The one fully retired Pathologist I know of is a WWII veteran. There are NO other "retired" pathologists in my area who dont at least attempt to do PT stuff, many in their late 60s to early 70s and some with very serious health issues.

The absurd retirement wave that was spoken of by CAP leadership as early as 1998 was utter and complete fiction. And Im sure as early as 2000, they knew it was fiction but continued to flood the field with trainees and hope for the best.

Obviously on the coasts there will be bell curve abberations due to the high cost of living etc. but if you charted total career length by speciality, Pathology would be WAYYYY far out on the curve, if not the the extreme outlier. And therein lies the disaster of the CAP planning commissions on future speciality need.

 

[Silent Cool]

There is here for sure. The one fully retired Pathologist I know of is a WWII veteran. There are NO other "retired" pathologists in my area who dont at least attempt to do PT stuff, many in their late 60s to early 70s and some with very serious health issues.

The absurd retirement wave that was spoken of by CAP leadership as early as 1998 was utter and complete fiction. And Im sure as early as 2000, they knew it was fiction but continued to flood the field with trainees and hope for the best.

Obviously on the coasts there will be bell curve abberations due to the high cost of living etc. but if you charted total career length by speciality, Pathology would be WAYYYY far out on the curve, if not the the extreme outlier. And therein lies the disaster of the CAP planning commissions on future speciality need.

I'd guess Psych, Path, Rads, and Derm have the longest career spans in medicine. Actually a great perk of those fields, I think.

 

[MOHS_01]

I'd guess Psych, Path, Rads, and Derm have the longest career spans in medicine. Actually a great perk of those fields, I think.

Agreed

 

[member0007]

I am not one to complain about the elderly maintaining employment because about 8/10 of the older pathologists are very good. The problem is the other 20% and the incompetence that exists with the 20% or so older pathologists are really troubling. For instance, the former chairman and his buddy of the department at Mount Sinai Medical Center have both went on to equivalent jobs in academia after being involved in a variety of shenanigans, including, but not limited to messes that questioned their skills as a pathologist. It seems that MOC is not going to affect them because they were grandfathered into the system or something like that 🙁 I guess they are welcome to skim cash off the top and be a total drain on the system, despite all of their wrong diagnoses to incompetent diagnoses. 😡

 

[Substance]

I am not one to complain about the elderly maintaining employment because about 8/10 of the older pathologists are very good. The problem is the other 20% and the incompetence that exists with the 20% or so older pathologists are really troubling. For instance, the former chairman and his buddy of the department at Mount Sinai Medical Center have both went on to equivalent jobs in academia after being involved in a variety of shenanigans, including, but not limited to messes that questioned their skills as a pathologist. It seems that MOC is not going to affect them because they were grandfathered into the system or something like that 🙁 I guess they are welcome to skim cash off the top and be a total drain on the system, despite all of their wrong diagnoses to incompetent diagnoses. 😡

Dude, the more I read what you write, the more I wonder whether you're going to be another one of those murderous nutjobs.

Stop being so vitriolic. Get on with your life.

 

[member0007]

Dude, the more I read what you write, the more I wonder whether you're going to be another one of those murderous nutjobs.

Stop being so vitriolic. Get on with your life.

Wow dude, you are being presumptive. I don't see any problem with a little venting on a topical issue.

 

[2121115]

I am not one to complain about the elderly maintaining employment because about 8/10 of the older pathologists are very good. The problem is the other 20% and the incompetence that exists with the 20% or so older pathologists are really troubling. For instance, the former chairman and his buddy of the department at Mount Sinai Medical Center have both went on to equivalent jobs in academia after being involved in a variety of shenanigans, including, but not limited to messes that questioned their skills as a pathologist. It seems that MOC is not going to affect them because they were grandfathered into the system or something like that 🙁 I guess they are welcome to skim cash off the top and be a total drain on the system, despite all of their wrong diagnoses to incompetent diagnoses. 😡

It is quite clear that you have an axe to grind, because you mention the Mt Sinai guy in every post. Did he sleep with your girlfriend? Steal your lunch money?

 

[deleted314957]

I am not one to complain about the elderly maintaining employment because about 8/10 of the older pathologists are very good. The problem is the other 20% and the incompetence that exists with the 20% or so older pathologists are really troubling. For instance, the former chairman and his buddy of the department at Mount Sinai Medical Center have both went on to equivalent jobs in academia after being involved in a variety of shenanigans, including, but not limited to messes that questioned their skills as a pathologist. It seems that MOC is not going to affect them because they were grandfathered into the system or something like that 🙁 I guess they are welcome to skim cash off the top and be a total drain on the system, despite all of their wrong diagnoses to incompetent diagnoses. 😡

Why don't you drop this chip? You have gone beyond pathetic and into some real psychopathology.

 

[member0007]

All I am doing is giving an example of why being paid for quality or whatever is garbage. You will see incompetent boobs make a lot money, get respect for being no better than a common racist and sexist bigot and thug, and it will be propagated by their yay sayers ad infinitum and by the sidestepping into equivalent positions. I get that pathology is not the military but with only about 150 residencies in the country, this is the sort of thing that happens all the time. Certain people can simply get another position in academia as chair of the department and so on, even if they are well-known to be completely corrupt and diabolical.

 

[deleted314957]

All I am doing is giving an example of why being paid for quality or whatever is garbage. You will see incompetent boobs make a lot money, get respect for being no better than a common racist and sexist bigot and thug, and it will propagated by their yay sayers ad infinitum and by the sidestepping into equivalent positions. I get that pathology is not the military but with only about 150 residencies in the country, this is the sort of thing that happens all the time. Certain people can simply get another position in academia as chair of the department and so on even if they are well-known to be completely corrupt and diabolical.

Good to see you've gotten over it.

 

[Pathwrath]

There are so few actually fully retired pathologists that I know, each one is essentially a legend around here.

Leaving aside the ones who still worked after their "retirement" and the ones forced to retire (terminal illness or terminal incompetence), I know of exactly two in my area.

 

[member0007]

It is quite clear that you have an axe to grind, because you mention the Mt Sinai guy in every post. Did he sleep with your girlfriend? Steal your lunch money?

Much worse, the incompetent boobs stole the cookie right out of my mouth and are poisoning my child, so to speak.

 

[LADoc00]

Leaving aside the ones who still worked after their "retirement" and the ones forced to retire (terminal illness or terminal incompetence), I know of exactly two in my area.

ah yes I did not include any of the forced retirements from career implosion and firings. If I did there would be several more "retired pathologists" about my area...