When will fee for service go out completely ?

[Nephro critical care]

---

Members do not see this ad.

Looking ahead to that time in the (hopefully) close future when fee for service will go out completely. The fee for service will be replaced by performance bonuses/penalties based on following evidence based guidelines. There should be some RVU incentive but small in comparison to total salary. These multiple insurances will be replaced by a single payer system. The current tort system will be replaced by medical panels that will judge/arbitrate based on whether EBM guidelines were followed. Similarly overly defensive medicine will be punished as well. Pharma companies will be forced to negotiate with the single insurance payer, no arbitrary setting of prices. Medications will not be overpriced while they are on patent and junked as soon as they go off patent.
Physician owned ASCs will be forced out of business and similarly surgeons double booking surgeries and doing too many surgeries especially the ones without significant evidence for benefit like lumbar spine surgeries will be penalized.
In short in this upcoming future doctors will make good money 150-300 K and have a comfortable life but no one will be allowed to bleed the system whether doctors , medical CEOs , pharma or Wall Street. In return medical school tuition should go down and the whole population will be covered with health insurance for about $5000 a person per year.

 

[Psych_hopeful]

Looking ahead to that time in the (hopefully) close future when fee for service will go out completely. The fee for service will be replaced by performance bonuses/penalties based on following evidence based guidelines. There should be some RVU incentive but small in comparison to total salary. These multiple insurances will be replaced by a single payer system. The current tort system will be replaced by medical panels that will judge/arbitrate based on whether EBM guidelines were followed. Similarly overly defensive medicine will be punished as well. Pharma companies will be forced to negotiate with the single insurance payer, no arbitrary setting of prices. Medications will not be overpriced while they are on patent and junked as soon as they go off patent.
Physician owned ASCs will be forced out of business and similarly surgeons double booking surgeries and doing too many surgeries especially the ones without significant evidence for benefit like lumbar spine surgeries will be penalized.
In short in this upcoming future doctors will make good money 150-300 K and have a comfortable life but no one will be allowed to bleed the system whether doctors , medical CEOs , pharma or Wall Street. In return medical school tuition should go down and the whole population will be covered with health insurance for about $5000 a person per year.

=/

This sounds kinda like a utopia. And call me cynical, but I feel like if something is too good to be true, it generally is. I guess I would want to know: how would you intend for all health insurances to unite and become a single company that would provide for this single payer system?

 

[Nephro critical care]

It is a little bit utopian. But it is practiced to a great extent in the rest of the developed world. Will not happen on Trump's watch but I am sure if Bernie Sanders was president we would be talking about this.

 

[Psych_hopeful]

It is a little bit utopian. But it is practiced to a great extent in the rest of the developed world. Will not happen on Trump's watch but I am sure if Bernie Sanders was president we would be talking about this.

Actually it could. There are many states in this country controlled by Democrats. My question is: in their states, why hasn't a state wide single payer system been instituted as of yet? Why do we not have Medicare for all in Vermont?

 

[jdh71]

Looking ahead to that time in the (hopefully) close future when fee for service will go out completely. The fee for service will be replaced by performance bonuses/penalties based on following evidence based guidelines. There should be some RVU incentive but small in comparison to total salary. These multiple insurances will be replaced by a single payer system. The current tort system will be replaced by medical panels that will judge/arbitrate based on whether EBM guidelines were followed. Similarly overly defensive medicine will be punished as well. Pharma companies will be forced to negotiate with the single insurance payer, no arbitrary setting of prices. Medications will not be overpriced while they are on patent and junked as soon as they go off patent.
Physician owned ASCs will be forced out of business and similarly surgeons double booking surgeries and doing too many surgeries especially the ones without significant evidence for benefit like lumbar spine surgeries will be penalized.
In short in this upcoming future doctors will make good money 150-300 K and have a comfortable life but no one will be allowed to bleed the system whether doctors , medical CEOs , pharma or Wall Street. In return medical school tuition should go down and the whole population will be covered with health insurance for about $5000 a person per year.

Guidelines are largely horsehit though. Why you'd want to move to a system that wasn't actually . . . scientific . . . seems odd. To me.

There is nothing about leaving FFS that will stop defensive medicine, or get rid of the law that doesn't allow CMS to negotiate drug prices.

 

[Psai]

I will never understand the obsession with what physicians are paid. Why not focus on administrator pay? They add nothing to the system and are actually detrimental to patient care with their adherence to policy. Their ranks get bloated to the tune of hundreds of thousands of dollars a year.

 

[Nephro critical care]

Fee for service is a totally corrupt system. In a private hospital where several groups are competing for consults we see a lot of inappropriate consults. I worked in a private hospital in Louisville and saw ID/cards/nephrology groups just fighting for consults to the point that a hospitalist director was forced to resign just because of pressure from these groups. I saw an ID physician who was making millions seeing every single UTI/PNA . He would see about 70-80 pts a day and never sign off . Hospitalists or PCPs would on admission call 5 consults and actually be the last to see the pts and do the H&P even after 5 consultants had seen the pt. Nephrologists would still see the pt after creatinine was 0.9 just to manage HTN with amlodipine or for resolved AKI. The only people slow to see pts were GI because they were busy scoping pts in their surgical centers.
Even EBM guidelines in USA are not free from corruption. Big pharmas manipulate a lot of studies along with their paid physicians and come up with these studies published in big journals which have statistical benefit but clinically have no meaningful benefit as compared with old tried and tested drugs. And because the FDA is playing their game as well they never crack down. Example colchicine , ticragrelor and a whole slew of drugs in last 10 years. Every drug last 10 yrs or as long as it is on patent and then is discarded as soon as it goes generic. Plavix was milked for 10-15 yrs and as soon as it went off patent pharma companies came up with ticagrelor/prasugrel. Notice how as soon as statins have gone on patent their is a concerted effort by pharmas to publicize myopathic effects of statins just so that the biologic cholesterol lowering agents can be the new fad.
I can keep going on about all the inappropriate spine surgeries /orthopedic surgeries etc that are done just under FFS. Just a gigantic corrupt system designed to milk money with no real benefit.
If US physicians went to other countries they would just not be able to compete. Because those physicians are really clinicians, with good physical exam skills and real clinical judgement not dependent on lab/radiological testing. And therefore really efficient and able to cure/great pts at 1/10th of the cost it takes in the US.

 

[chessknt]

Fee for service is a totally corrupt system. In a private hospital where several groups are competing for consults we see a lot of inappropriate consults. I worked in a private hospital in Louisville and saw ID/cards/nephrology groups just fighting for consults to the point that a hospitalist director was forced to resign just because of pressure from these groups. I saw an ID physician who was making millions seeing every single UTI/PNA . He would see about 70-80 pts a day and never sign off . Hospitalists or PCPs would on admission call 5 consults and actually be the last to see the pts and do the H&P even after 5 consultants had seen the pt. Nephrologists would still see the pt after creatinine was 0.9 just to manage HTN with amlodipine or for resolved AKI. The only people slow to see pts were GI because they were busy scoping pts in their surgical centers.
Even EBM guidelines in USA are not free from corruption. Big pharmas manipulate a lot of studies along with their paid physicians and come up with these studies published in big journals which have statistical benefit but clinically have no meaningful benefit as compared with old tried and tested drugs. And because the FDA is playing their game as well they never crack down. Example colchicine , ticragrelor and a whole slew of drugs in last 10 years. Every drug last 10 yrs or as long as it is on patent and then is discarded as soon as it goes generic. Plavix was milked for 10-15 yrs and as soon as it went off patent pharma companies came up with ticagrelor/prasugrel. Notice how as soon as statins have gone on patent their is a concerted effort by pharmas to publicize myopathic effects of statins just so that the biologic cholesterol lowering agents can be the new fad.
I can keep going on about all the inappropriate spine surgeries /orthopedic surgeries etc that are done just under FFS. Just a gigantic corrupt system designed to milk money with no real benefit.
If US physicians went to other countries they would just not be able to compete. Because those physicians are really clinicians, with good physical exam skills and real clinical judgement not dependent on lab/radiological testing. And therefore really efficient and able to cure/great pts at 1/10th of the cost it takes in the US.

Feel free to gtfo and go work with the real physicians in their perfect healthcare systems then...

Ffs has its issues but pay based on quality is a pipe dream because nobody has been able to reliably quantify what quality means:
a1c under 7 is great but we all know that there are factors beyond the control of physicians thta make this impossible in many people.
30 day readmission for chf exacerbation? Have you ever met these people?
And so on.

Also fyi Medicare has a whistleblower bonus for fraud like you describe above--go report those people and walk away with millions then you can go retire in Europe and live in paradise.

 

[CCM-MD]

Feel free to gtfo and go work with the real physicians in their perfect healthcare systems then...

Ffs has its issues but pay based on quality is a pipe dream because nobody has been able to reliably quantify what quality means:
a1c under 7 is great but we all know that there are factors beyond the control of physicians thta make this impossible in many people.
30 day readmission for chf exacerbation? Have you ever met these people?
And so on.

Also fyi Medicare has a whistleblower bonus for fraud like you describe above--go report those people and walk away with millions then you can go retire in Europe and live in paradise.

I know someone made a few million dollars from whistleblowing. Funny thing is he still sees patients at the hospital he reported to CMS.

 

[DrfluffyMD]

I know what I'll be doing as a radiologist if we move away from fee for service.

I'll block 70-80% of all imaging scans ordered, read 7 scans a day which will take me about 70 minutes to do, and spend the rest of the day watching netflix while occasionally tell you that you won't get your Renal ultrasound because patient is unlikely to have obstructive nephropathy based on your exam.

I sure will love the system. It's probably cheaper for the country to pay me sit around doing nothing than pay me to read 50 scans.

 

[Nephro critical care]

I can't really gtfo ; I have been corrupted as well by the almighty dollar. Infact I am thinking of leaving my idealistic non RVU based hospital and join my friend in Louisville seeing 80 BS consults every day and getting my share of the pie.
I am going to trash every single ole generic drug, not prescribe any drug that costs insurance < $500. Admit and stress every 25 yr old with non cardiac CP and likely angio too. Open my own ASC ,hire CRNAs and scope every Pt with GI complaints prior to even seeing him with my own hired CRNA and send the biopsies to my own hired pathologist. Do back surgeries on every disability seeking bum with the slightest disc prolapse and do a full fusion. Sit on pharma board do research on old generics like colchicine and get FDA approval and a new patent and jack price up from 10 cents to $10 a pill. We will give a nice licensing fee to FDA and then promote it heavily to rheum guys and get $150 million. With all that money I could be health secretary and get my own chartered plane to all meetings. That's the way we roll in the USA.

 

[bronx43]

I can't really gtfo ; I have been corrupted as well by the almighty dollar. Infact I am thinking of leaving my idealistic non RVU based hospital and join my friend in Louisville seeing 80 BS consults every day and getting my share of the pie.
I am going to trash every single ole generic drug, not prescribe any drug that costs insurance < $500. Admit and stress every 25 yr old with non cardiac CP and likely angio too. Open my own ASC ,hire CRNAs and scope every Pt with GI complaints prior to even seeing him with my own hired CRNA and send the biopsies to my own hired pathologist. Do back surgeries on every disability seeking bum with the slightest disc prolapse and do a full fusion. Sit on pharma board do research on old generics like colchicine and get FDA approval and a new patent and jack price up from 10 cents to $10 a pill. We will give a nice licensing fee to FDA and then promote it heavily to rheum guys and get $150 million. With all that money I could be health secretary and get my own chartered plane to all meetings. That's the way we roll in the USA.

What you're talking about won't happen until a massive shift in macroeconomics forces the US to change, and when that happens, it won't be pretty. I've been thinking about this for nearly a decade now, and that's the conclusion I've come to. There is little to no chance that the US will voluntarily move to a single payer system and drastically cut costs. Two reasons why this won't happen... first off, drastic downsizing of the health care sector will contract your aggregate demand, especially if this change is to happen too quickly. The healthcare industrial complex, much like the military industrial complex, has become little more than a direct inlay for fiscal policy that is mascarading as a greater good. Despite calls for a single payer system like what Sanders is preaching, I don't think other members of the leadership would ever allow the health care sector to be squeezed. In fact, even if Sanders does get his way, I suspect the waste in the system will simply flow into different crevices - perhaps administrators and bureaucrats. Second, I simply don't see the public as being willing to accept a drop off in the amount of care provided. I don't see any feasible way where you can change to a European system without having a drop off in productivity of such a system.

Therefore, we're stuck with this until some event changes the global financial system, thus removing the dollar as the hegemonic currency. When that happens, the US will no longer be able to act as the main engine of global demand, and will have to balance out its current account deficit. How or when this happens is impossible to predict.

 

[NotAProgDirector]

I don't disagree with you. Although I work in my Ivory Tower where we try to use consults judiciously, I've also worked in and reviewed transfer charts from community hospitals where what you describe happens -- anyone with a creat of 1.4 gets a renal consult, all positive cultures get an ID consult, etc. At my institution you'd be shot for doing this, at a community site it's standard operating procedure -- either to maximize billing, or to ensure patients get the best care possible, pick your spin.

The problem with your argument, however, is not that FFS is a corrupt system. The problem is that any system can be corrupted -- the nature of the corruption changes based upon the rules. In general, humans try to maximize the income/work ratio. Hence, in a FFS, generating short consults that honestly can be completely templated and dropped into a chart generates income for little work. Change to your quality metrics / non RVU based system, and people will decrease the number of patient visits they have. Why see 30 patients a day if you make the same salary seeing 15? And if your answer is that some administrator decides how many patients you have to see for your job, that's a dangerous slope to slide down. I assume from your username that you're Neph. Would be easy to tell you that you need to oversee 100 HD patients daily. Or 200. Or why not 300?

And as mentioned above, measuring quality is difficult. In fact, I'll posit that it's impossible. It's a non-linear/complex (mathematically) system, any attempt at measuring it is doomed to failure, because small changes in inputs (patient factors) lead to wild changes in outputs (measured quality). In fact, we can already see the unintended consequences of using oversimplified metrics of quality. Surgeons are measured on their 30 day mortality. Seems like a reasonable measure, right? It's clearly a hard outcome -- either you're dead or you're not (ignoring brain death / PVS). And most people would want to be seen by a surgeon with a low death rate. But the unintended consequence here is that surgeons will no longer take sick patients to the OR for "last chance" surgery -- if they die (which is quite likely), then the surgeon get's dinged. Another example is fertility clinics -- there was a great piece on NPR about this, where clinics are measured on what percent of implantation attempts result in a pregnancy. Patients are very sensitive to these metrics -- it's often how they choose which clinic to attend (esp because often this treatment is private pay, so more success = less cost). So many clinics implant multiple embryos, because this increases your implant rate. But, it also increases your multiple preg rate -- and the complications of multiples in IVF is extremely high.

Last, I would point out that your utopian system already exists in the US. It's the VA. It's basically a single payor. They negotiate for drug prices. There's no tort issues. There's little drivers for RVU production. There's a universal formulary. There's a single EMR. But it's certainly not the Garden of Eden. It has exactly what you'd expect in a top-down socialistic system -- massive bureaucracy and rules, people often working as little as possible since there's no driver to increase, mixed quality using simplistic measures, etc.

I'm not a fan of FFS. But I'm not convinced that anything proposed so far is any better. ACO's won't really work (and many have already failed). Bundled pricing may help somewhat, but again people will game that system for profit. Direct Primary Care is a real possibility -- although that can be gamed with cherry picking healthy patients only. Every system can be corrupted.

 

[Siggy]

Last, I would point out that your utopian system already exists in the US. It's the VA. It's basically a single payor. They negotiate for drug prices. There's no tort issues. There's little drivers for RVU production. There's a universal formulary. There's a single EMR. But it's certainly not the Garden of Eden. It has exactly what you'd expect in a top-down socialistic system -- massive bureaucracy and rules, people often working as little as possible since there's no driver to increase, mixed quality using simplistic measures, etc.

...and, as with the consult today (I'm on my pulm rotation through the VA this month), you still get bogus consults.

 

[Nephro critical care]

Yes neither FFS nor a non RVU system are perfect. I have worked in both and while from a physician perspective the FFS system works great those physicians do drain the system horribly.
In those private big hospitals in Louisville the private practice would welcome all the easy consults creatinine 1.2. Thosectook little work and paid well with no stress. In fact they would have 20 consults with creat 1.2 and the one real GN pt who was really sick and complicated needing cytotoxics would be shunted to the University hospital just because they didn't want /or even know how to deal with it. And they would try to get the CKD stage 4s on dialysis because then they would become a regular source of income that they could get on HD and get to see every week on HD.
Another example would be of variation in neuro/spine surgeons who I know one is a non RVU based employed academic neurosurgeon and a community based spine surgeon . The academic neurosurgeon will not operate on the spine unless their is a real neuro deficit corresponding with an anatomical abnormality. The community spine surgeon does about 2 -3 surgeries every day just on some disc protusion which I seriously doubt is clinically relevant. I suspect many of his patients just go to him to get an disability so they don't have to work and after 2 or 3 surgeries go on to have 'failed back syndrome' and then go on to pain medicine for more epidural injections and finally end up on the boat load of OxyContin , Soma and Valium that was their ultimate goal. And then show up every week to the ED for the IV D drug when they run out of their prescriptions. Living the high life. I am sure with my weight issues if I went to this spine surgeon he would find something in my spine and operate and then I could get my disability and my D drug and love the high life and get into the medical cannabis plan for intractable pain. I want to be a gainful member of society and a support to my wife and 2 kids so I did not take this path.
But then I have also worked in hospitals where there is very little RVU bonus. There consultants were very mean to the hospitalists and every consult was met by the standard reply " why are you calling me " "can't you manage this yourself ".
And tort is good in some ways too. I came from a 3rd world country and there poor people died like flies in hospitals. Doctors just didn't give a damn. I saw a severe pancreatitis patient just die in my hospital from lack of IV access. No one could get a peripheral and no one knew how to put a central line. Another patient had a VFib cardiac arrest basically because the ED doc sat in his office and told cardiology to come from 2 blocks away to come to do CPR as he was too lazy to do it himself.
I am curious though what people experience is in the Scandinavian countries or even NHS where there is some doctor responsibility but not defensive medicine to the point of gross inefficiency and doctors are not working on pure profit.
One of the cases I respect in the Charlie Gard case in England where there the Great Ormand Street hospital showed guts in from of the family instead of being painted as the bad guys. They knew the mitochondrial depletion syndrome and persistent/vegetative state /brain injury/seizures was not reversible and the child did not have acceptable quality of life and stuck to their beliefs in front of the family and courts. Kudos to them to stick to their beliefs. US physicians would be too scared about being dragged in front of a jury by some scumbag lawyer and then being on the hook for $ 50 million despite providing the best care and just in the end God making the choice he had already made.