Quantity vs Quality and pathology

[pathstudent]

The drumbeat in the news is that our healthcare system is broken because physicians are incentivized by quantity of care rather than quality of care ("from volume to value") I have also heard statements like, "doctors order more tests because they make more money for each test". I don't really think that is how it works. When a primary care doc orders tests and studies, I don't think he or she makes more money.

I also resent the sentement that we care more about quantity than quality. I believe the two are often times closely related (i.e. the surgeon with the highest volume has the most experience and best outcomes which begets more business and more experience. Value begets volume and volume begets value).

Moreover, "the term fee for service" has become a dirty concept. It is important to remember that we life in a market based society where you are reimbursed for each unit produced. We as pathologists make widgits (aka diagnoses), and to say we should not be reimbursed on a per widgit basis goes against our whole economic system.

As we move towards bundled payments and ACOs; hopefully, CMS and others will realize that pathologists don't manage paitients with diabetes. We make widgits. FFS should apply to us. While we can help save healthcare costs via education and lab management, we can't be strangled in a "prospective payment" system.

To make healthcare and medicare work, we should not abandon FFS, we should limit services available to patients whose care is paid for by taxpayers. We need so called "death panels". If you are old with metstatic cancer or demented in a nursing home and in need of a hip replacement, you shouldn't get the rare expensive chemotherapy or a new hip unless you want to spend your own life savings on it. We need to ration healthcare when it comes to public funds.

---

Members don't see this ad.

 

[KCShaw]

A PCP may not generally make money from the performance of the test, but they do when they bring the patient back a week or two later to "go over the results."

One of the problems with the spiral is also the cost of medical education -- the cost to become a doctor continues to go up in the face of decreased income, leaving an MD with fewer and fewer choices but to milk the system. Of course, the average layperson or politician just sees a salary and has no understanding of the context. That's not to say that a small percentage of physicians don't make a lot more than perhaps they "should", but so do football coaches, or any other profession you can think of.

Another problem continues to be civil and malpractice litigation -- it doesn't matter how well evidenced your decision tree is, if you don't CT and refer to GI everybody who shows up with some vague nausea then eventually someone is going to lose a lawsuit (even if the "fault" balance is only 10% ... one of the quirks of civil cases). And to be honest, it doesn't matter if you win or lose, simply being sued is a financial, mental, and professional drain. The system essentially MANDATES overspending, by not only failing to protect the decision makers at the physician level but also accusing them of poor or improper practice even in the face of reasonable evidence. On the rare occasions I go to a doctor (thankfully still relatively young and fairly healthy), it seems like I spend more time declining tests than they do on the history and examination. Seriously, last routine visit they said they were doing some basic bloods and I fasted for a lipid profile, but I ended up with also an insulin level and genetic studies for platelet, lipoprotein, and coagulation markers, among other things (far be it from me to know what the latest recommendations are, but really, on a 30-something with no significant history?). Somehow none of it was out of pocket, but it's being paid for somewhere. I feel much better knowing my homocysteine level now, though.

Anyway, seems to me like the problem is being looked at from the wrong end by the wrong people who don't much understand the system.

 

[thebouque]

On the rare occasions I go to a doctor (thankfully still relatively young and fairly healthy), it seems like I spend more time declining tests than they do on the history and examination. Seriously, last routine visit they said they were doing some basic bloods and I fasted for a lipid profile, but I ended up with also an insulin level and genetic studies for platelet, lipoprotein, and coagulation markers, among other things (far be it from me to know what the latest recommendations are, but really, on a 30-something with no significant history?). Somehow none of it was out of pocket, but it's being paid for somewhere. I feel much better knowing my homocysteine level now, though.
.

Ordering those advanced lipid tests to a 30 something with no history is a very bad use of resources. It's almost malpractice... And insulin level?? I don't even think that fasting or random blood glucose is recommended at that age with no particular history.

 

[KCShaw]

Yeah, I usually catch stuff like that before it gets ordered. "Basic" lipids, OK. But I'm pretty sure I didn't need to know several different genetic markers for coagulation risk. Individuals still don't (all) practice cost effective population preventive care/diagnostics -- it's an easy sell to say "I do all this -extra- stuff for -you- that you won't get across the street at that cold hearted academic center..." I've been happier with the pediatrician, but still there have been a couple of times we've cut them off at the knees; at least they were following a recommendation, though I don't know where it came from (doing lead levels on any kid that spends time with someone who goes fishing. Seriously? From the epidemic of kids with lead poisoning after swallowing lead weights, which are always just left lying around?). Anyway, I digress.

Point is that it's very, very widespread that physicians order above and beyond reasonably evidenced algorithms. And that's without talking about treatment -- antibiotics, anyone? It's selected for in medical school, further inbred in residency, and essentially mandated by the existing litigation process. My suspicion is that ACO's, as described to me, would make it -worse-, not better. Again, the focus is on the individual patient, when for the system to work efficiently it has to be on the population -- which runs counter to what people generally feel about themselves.

 

[Torsed]

Ordering those advanced lipid tests to a 30 something with no history is a very bad use of resources. It's almost malpractice... And insulin level?? I don't even think that fasting or random blood glucose is recommended at that age with no particular history.

Was it the provider an MD or a mid-level provider? Curious to know.

 

[KCShaw]

MD.

I don't think it's a particularly uncommon trend -- quite the opposite; even though my firsthand knowledge on the subject is certainly limited, it's the sense I get from where I sit.