Salary vs. Fee For Service: Good vs. Evil?

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A colleague said, “Salaried clinicians: we only care about the patients; patient care. You guys; you always think about billing. We only think about patients.”

Salaried physicians and nurses claim moral purity.

They never consider money when caring for patients.
They care selflessly.
Though grateful for their pay, it never comes to mind when they provide care.
They own the high-road…

At least until their shift ends.

Or they go on break.
Or they have a sniffle and need a sick day.
Or they want to go to a popular parade and use a sick day to do so.

Go ask them: salaried workers insist they provide better care because their concern is unadulterated by money. Just don’t ask whether their purity is influenced by the attention they give to the clock.

How to make more money

To make more money on fee for service you need to work MORE. You need to see more patients, perform more procedures, and somehow do more work. You have to help more people.

To make more money on salary you need to work LESS. Your earnings per hour of work increase if you spend more time not working (breaks, lunch, clean-up, etc.). Your earnings per unit of effort rise if you expend less effort; in other words, work less.

How to challenge altruism

Salaried workers – ask them to skip a break, stay late, or come in to work for free…or even just forgo overtime.

Fee for service workers – ask them to do something they cannot bill for.

Working for free

Salaried workers occasionally work without pay to see patients by staying late or shortening their coffee or meal breaks. Those who do so routinely are pitied by their peers for working any harder than necessary or for not being skilled enough to take their full break times.

Fee for service providers continually provide care for free because so many necessary things are unbillable. Dozens of times each shift providers are asked to do necessary things for which they cannot bill.

Yes but…

What about guys who bill for work they didn’t do? That’s called fraud; you must report it. People lose their licence and could face criminal charges or jail time. You cannot dismiss fee for service with hand-waving about fraud.

Don’t fee for service workers cut corners? Don’t they leave out patient education, thorough physical exam, note taking, etc., etc., etc.? Without question, FFS workers face the temptation to shorten clinical encounters just as salaried workers face the temptation to lengthen them by doing things that do not add value for patients to avoid burning energy seeing new patients.

Solutions?

Ask patients. Measure outcomes. Report performance. Reward efficiency.

We should compare payment using criteria that add value for patients: patient satisfaction scores, patient wait times, clinical quality indicators. We should not invent arbitrary measures of quality (e.g., long charts) that often add no value to patients.

Moral corruption exists everywhere: in both salaried and fee for service settings. People determined to get paid for doing less than necessary will succeed regardless of the remuneration model.

Let’s focus on outcomes. Judging others’ motives gets us nowhere.

EMR – Bigger Is Not Better

Docs spend more time with electronic health records than with patients. Many blame electronics. True, bad systems eat hours of nurse and physician time, but the biggest waste is fat charts.

If bigger is better for patient charts, then medical students make the best charts; staff physicians the worst.

Every year, trainees get better at sharpening details. Expertise leads to focus on critical information: everything that does not add value gets left out. Charts get shorter…until providers start padding charts for other reasons.

Modern patient charts aren’t just about patients.

Charts get longer to:

1. Protect against Lawsuit:

A long chart makes it tough to prove providers weren’t thorough. You can prove you thought about all sorts of things by listing all the negative responses you found even though the negatives don’t help the patient.

2. Protect against audit from your regulatory college:

The overseers/authorities/police believe they know what makes a great chart. They support #1 above and enforce it, and they (groups of lawyers and lay-people mostly) define ‘best practice’.

3. Protect against billing audit:

Long charts look like lots of work was done.

Value Added?

Would an informed patient willingly pay for long notes that were created to protect providers?

Do long lists of ‘pertinent negatives’ add anything for patients? Sure, they ‘prove’ providers considered a differential diagnosis, but considering a differential diagnosis is core medical practice; why should they prove they did it?

The whole medical decision-making heuristic rests on a differential diagnosis approach; why prove it over and over on every single chart?

As a provider, if you just wrote the diagnosis, does that mean you suddenly became anti-differential diagnosis? Even if you recorded pages of negative findings and came up with the wrong diagnosis, does that help the patient any more than just writing the wrong diagnosis in the first place? All it proves is that you were thoughtfully wrong.

Two types of Complaints

A. You know what’s going on:

This chart needs positive historical points and physical findings, diagnosis, and treatment. That’s it. Nothing else adds value for the patient.

B. You have no clue what’s going on:

This chart needs more. You should write a book: everything you thought about and why it doesn’t fit. In fact, long charts define clinical uncertainty, not clinical excellence.

If patient charts should be about patients, we need to:

1. Change expectations:

Focus only on what adds value for patients.

2. Change charts:

The whole process could be done with macros and tick-boxes. Only critical findings (positives, diagnosis, treatment plan) need manual entry.

When physicians and nurses go back to review a chart, they NEVER need all the information in it. NO ONE DOES, except non-providers! Clinicians look at old charts to find 1-2 critical pieces of information that have meaning for their patient.

How short would your chart be if you weren’t worried about lawsuits and audits? What needs to be in the chart if only patient benefit mattered?

Number of specialized doctors who are unemployed growing, study finds | Toronto Star

http://www.careerealism.com/ — www.careerealism.com/

Number of specialized doctors who are unemployed growing, study finds | Toronto Star.

Patients wait over a year to see consultants, especially in rural areas. Patients and physicians are frustrated. This article adds gasoline to the fire.

My Uncle, a rural physician, suggests a central registry of consultants listing their wait times and ability to see referrals.

Lack of operating room time keeps many surgeons unemployed. Patients wait; surgeons work part-time; the system ‘saves’ money.

Intolerable.