How to Pay Doctors? Salary, Piecework or Quality?

Salary-negotiation-job-interviewThis post appeared in The HealthCare Blog and in A Country Doctor Writes.  Dr. Duvefelt shares his experience in Sweden on salary and how this impacts patients’ experience and expectations.  I include the whole piece from the Healthcare Blog here:

“A long time ago, when I worked in Sweden’s Socialized health care system, there were no incentives to see more patients.

In the hospital and in the outpatient offices there were scheduled coffee breaks at 10 and at 3 o’clock, lunch was an hour, and everyone left on the dot at five. On-call work was reimbursed as time off. Any extra income would have been taxed at the prevailing marginal income tax rate of somewhere around 80%.

There was, in my view, a culture of giving less than you were able to, a lack of urgency, and a patient-unfriendly set of barriers. One example: most clinics took phone calls only for an hour or two in the morning.

After that, there was no patient access; no additions were made to providers’ schedules, even if some patients didn’t keep their appointments, not that there was a way to call and make a same-day cancellation.

As my father always said: “There must be a reward for working”.

But, high productivity can sometimes mean churning out patient visits without accomplishing much, or it can mean providing unnecessary care just to increase revenue. For example, some of my patients who spend winters in warmer climates come back with tall tales of excessive testing while away.

A recent Wall Street Journal article offers an interactive display of doctors who collect the highest Medicare payments. The difference between providers in the same specialties across the country makes interesting reading. It is hard to imagine that many individual doctors are billing Medicare more than $10,000,000 per year.

So it might make sense to insure against paying for excessive care by also demanding a certain level of quality.

But defining quality is fraught with scientific and ethical problems, since quality targets really aren’t, or shouldn’t be, the same for all of our patients.

The scientific community, for example, knows that elderly diabetics with “ideal” blood sugars are more likely to suffer harm or die than those with sugars that are a little higher. Even though the American Diabetes Association has embraced higher blood sugar targets for older diabetics, many healthcare organizations’ quality assurance programs treat all diabetics the same and penalize doctors who individualize treatment goals in accordance with the scientific evidence or common sense.

In almost every area of medicine there are individual nuances that must be considered if we are to best serve each of our patients. It is ironic and very sad that, right now, those who pay us are looking for simple (or simplistic), universally applicable quality targets just as the explosion in our understanding of genetics is promising to usher in the era of “personalized medicine”.

Up until now, the gold standard of scientific research has been to prove which standardized interventions work best for large groups of patients, even if there are subgroups that aren’t helped at all by them.

Who should define the “quality” measures of our work?

The central question for how doctors might be paid for quality in the future hinges on the priorities of whoever holds the purse strings. Insurance companies, if we overlook profit motives that also exist, prioritize population management. They pay for what works for most people, knowing full well that some patients will not get the best care for their individual situations, for example when certain medications are not covered.

Politicians also favor the population view of health care.

If patients pay us directly, they expect us to deliver the care that works for them. If the Government or an insurance company pays us, they expect us to deliver care that meets their standards, because they don’t trust the patients – their constituents and customers – to know what is best for them.

And their focus is to have us do what helps most of our patients, even if some are not helped and some, or many, aren’t happy with what they are getting.

With all the political talk about “Patient Centeredness” during the current health care reform, may I suggest that patients need to be given more choice about how their health care dollars are spent. With limited choice and no responsibility, patients tend to feel entitled and deprived at the same time.

This creates a toxic environment for delivering health care. I have never met a patient who felt in partnership with his or her insurance company – ever.

And I don’t expect to.

In order to maintain what partnership is left today between doctors and patients, we need a cost-quality paradigm that is shared by patients and providers. We also need to foster and maintain a sense of stewardship that is elusive if all that is at stake is someone else’s money.

I think there are ways to achieve this.

Hans Duvefelt, MD is a Swedish-born family physician in a small town in rural Maine. He blogs regularly at A Country Doctor Writes where this piece originally appeared.”

(photocredit: blog.jobma.com)

Canadians Deserve Better Health Care

canadian-flag-640The ‘biggest court case in Canadian history‘ gets started in September.  The 30 minute video below gives you enough to start talking about it with your friends and colleagues.

You can also check out: Charter Health – Canadians Deserve Better Health Care

30 Second Summary:

  • 7 plaintiffs suing BC government under Charter of Rights
  • All suffered harm from waiting (e.g. teenager waited 27 months for spine surgery, now paralyzed)
  • Only country in world where illegal to purchase care
  • Canada ranks at bottom of numerous lists comparing care in other countries
  • Queue jumping by: federal prisoners, government employees, workers compensation, etc
  • One defendant, former Attorney General of BC, purchased private spine surgery in BC (!)
  • Current BC Minister of Health is a veterinarian
  • Plaintiffs arguing for same rights as animals
  • Arguing for same rights for those Canadians not in jail as prisoners get now

 

Regardless of which side of this case you support, we need to spread the word.  We need politicians to discuss this.

(photocredit: canadian-flag.org)

Healthcare Bureaucracy, Forms & Waste

no paper formsWestern civilization will not end from Ebola or nuclear disaster. It will choke to death under forms and bureaucracy.

Our tour guide spoke with both hands as he tilted our van through corners on the Amalfi coast in heavy traffic. I raised his blood pressure by asking him about Italian politics.

He told me how his friend struggled as a chef.

He spends more time filling out paperwork for government than cooking for customers!” he said in a thick accent.

Our guide gladly took cash for the tour. Everywhere else, we filled out paperwork with passport numbers so government could monitor the tourism industry.

Bureaucrats love forms. Without asking for much input, bureaucracy creates new forms like dandelions in spring.

Healthcare Bureaucracy

When politicians promise voters more healthcare services, it usually includes some kind of form for doctors to fill out. Forms take longer to fill, than patients take to see. Ergo, politicians’ promises produce less service, not more, if they include a form to fill out. (Thanks, Philip!)

For the most part, bureaucratic forms do not contain medication orders. They usually ask for signatures confirming medical condition, explanations about clinical features and regurgitated treatments that have all been recorded elsewhere. These forms get designed in cubicles to serve bureaucratic ends.

Provincial Ministries of Health and Medical Associations have bilateral provincial Forms Committees to try to limit the negative impact of forms on clinical care while still meeting bureaucratic goals. Even so, some frustrated physicians have created ‘Doctors Against Forms’ committees.

Helpful Forms: PPOs

However, clinicians want some forms. Medical pre-printed order sheets improve accuracy and save tonnes of time. Clinical protocols could be written out long hand by any physician any time. But PPOs that improve care move glacially through dozens of drafts reviewed by committees of non-clinicians and physicians with little experience on a specific PPO. Hospital Forms Committees hold enormous power. Without their imprimatur, patients don’t benefit from PPOs. It’s often easier to change an out-of-date form manually for each patient than to run the Forms’ gauntlet for an update.

Overregulation

Forms represent one tiny feature of overregulation. Healthcare bureaucracy always creates more work for itself.  It will never go on a diet. Touting accountability and audit, micromanagement will always bloat, will always crave more control.

Bureaucratic bloat drives cost, increases frustration and, most importantly, limits service.

Nobody likes whiners. Providers drowning in bureaucracy sound like whiners when they speak up. The only way to definitively erase bureaucracy is to demonstrate a better alternative.

 

(photocredit: eformsfactory.com)