Cream skimming triggers many doctors and all single-payer activists. It might be one of the most hated, uncollegial behaviours in medicine.
No one likes a colleague who takes all the easy patients and leaves the hard ones.
No one likes the idea of for-profit hospitals skimming all the easy cases and leaving the hardest ones for the public hospitals.
Why Cream Skimming?
Cream skimming exists because some patients are hard and others easy, even though each patient often carries the same fee. On top of that, some easy medical problems carry higher fees than harder ones.
For example, a toddler with a tiny laceration generates a visit fee plus a suture fee. It takes a few minutes to fix. Toddler leaves with a sucker in one hand, a wave in the other, and a huge smile on her face.
A weak and dizzy 80 year old with 6 non-English-speaking relatives often generates the same visit fee as the toddler, minus the suture fee. No smiles, suckers or happy parents.
It happens in all specialities. Cream exists: Some patients carry less risk, pay more, and require fewer brain cells to see.
Path to Incompetence
Committed cream skimmers cannot exist for long. No one became muscular by doing easy things. Easy guarantees mediocrity at best.
Cream skimming is the path to flabbiness in medicine. Doctors get mad at colleagues who “scoop all the easy patients.”
Doctors think that cream skimmers get ahead.
But medicine is a race. You need fitness to run. Wimps choose easy cases and build their reputation as the doctor no one wants to see.
Cream skimming might work for a week, or even longer in an area with severely rationed services. But it fails as a career goal. The colleague who “steals all the easy patients” becomes incompetent; ill-prepared for real medical crisis.
Success in medicine requires skill + effort + volume. Skill requires years of effort seeing a high volume of sick, complex patients. Getting really good at easy does not create good doctors.
This applies to institutions also. Patients want to be seen by doctors in institutions that are used to doing hard things.
No one wants a doctor who only sees pulled elbows and diaper rashes.
Doctors’ reputations come from doing hard things. Hospitals become famous by taking hard cases.
Concerns About Cream Skimming
Anti-cream-skimming activists use cream skimming as a moral indictment against any kind of private medicine.
Greedy private organizations skim all the easy patients and leave the hardest ones for the public hospitals. Only government can prevent cream skimming.
In one sense, legitimate cream skimming happens now, in our current system. It is called referral.
When a provider in the community cannot care for a sick patient in her private office, she refers them to the hospital. No one calls it cream skimming.
Furthermore, community hospitals see easier patients than tertiary teaching centres. We send the sickest patients downtown. It is called patient transfer, not cream skimming.
No doubt all clinics, whether public, private non-profit, or private for-profit, will continue to refer hard cases to hospitals. Again, that is appropriate referral or transfer, not cream skimming.
Finally, if a physician focusses his practice on a particular area within his specialty, that is not cream skimming either.
But what about private, for-profit hospitals and clinics? If Canada allowed for-profit hospitals to exist, surely they would skim the cream leaving all the hardest cases for the public system?
Hospital Cream Skimming
Hospitals and doctors cannot become famous by seeing easy cases; notorious perhaps, but not famous.
If private hospitals gain a reputation for only seeing easy patients, patients will not trust them. Institutions survive on reputation. Patients are not stupid. Word gets out: Do not go there.
Even so, hospitals might trick gullible patients into believing a hospital is great, when it is not. Leaving aside the assumption that most patients are gullible (they are not), could a for-profit hospital trick patients, skim the cream and leave the rest for public hospitals?
This could only happen if government fixed prices. If the price of care in a private hospital can adjust with demand, cream skimming cannot exist because the cream evaporates.
How To Create Cream
Cream only exists when a central authority arbitrarily fixes fees. Price fixing creates inefficiency: some prices are set too high and others too low. Price fixing creates cream.
If hospitals must compete to provide care for fees that are not fixed, they cannot skim the cream.
Even if hospitals choose to see only easy patients, competition drives down prices and evaporates the cream.
You cannot skim cream if cream no longer exists.
Look at laser eye surgery. The price has dropped, quality increased, and service is second to none.
Institutional cream skimming cannot exist unless governments fix prices or ration access and, at the same time, allow competition.
1) Fixed prices create inefficiency: fees artificially too high or too low. This creates cream.
2) Rationing creates scarcity. Underfunding, special licences, regulations, and legislation rations access for patients. Easy patients remain as cream to skim because access has been arbitrarily rationed.
Cream skimming would not exist unless government fixed prices, limited access, and then allowed competition to provide care.
Summary
Cream skimming triggers emotional reactions. We dislike it with good reason. However, the emotion might be more reaction than reason.
1) Physicians who cream skim become incompetent and inefficient.
2) Referring challenging patients to hospital is not cream skimming.
3) Great reputations come from seeing challenging cases, not by skimming cream.
4) Cream skimming can only survive if government sustains it.
Next time you hear of a colleague “seeing all the easy patients”, you should feel sorry for them, not envious.
And far from being the inevitable scourge of private finance, cream skimming can only survive under artificial government rules that create cream in the first place.
Photo credit: pexels.com Silvia Trigo
Without the “quick consults” the measly payment I received for a standard consultation would not have allowed me to feed my family, support us in our myriad endeavours and save for retirement. I needed the ear recheck, BP meds renewal, suture removal and other “cream” visits to compensate for the 20 to 30 minute consults for which I received $30. I did come to resent the walk-ins that saw these easy patients for the same fee. Today, the pharmacists are now taking these from us as have the NPs done for several years. While I can appreciate the concept of leaving the difficult patients for the better trained physician, concomitant with that should be a dramatic increase in the fee payable to reward the higher training and more difficult challenge. If that’s not to occur, then please allow me the “fast” patients too.
Solid comments, Ralph.
The cream exists because of price fixing. And to your point, we cannot survive without a mix of hard and easy patients.
The only silver lining in having other people skim off the easy patients is that the skimmers will never become experts. It guarantees that there will always be an increasing demand for your services.
Thanks for taking time to read and post a comment!
Cheers
Creatinga a higher ratio of loss leaders to cream , for any small business, is just cheap and selfish and shitty….there is also the rarely mentioned story of how cheper models of alternative care, like NPs, pharmacists, etc, will do this exact thing. Steal the cream. Have little impact on the truly ill. Save some money for the bankrupt sytem. But crush the highest talent with more complex and demanding cases….the boomer dementia wave coming is a good example. Stress and guv budgets will lead to more retirements, fewer talents , richer doc candidates (tuition for med school rising) , and less who are willing to take on the higher burden of even more loss leaders…the care level will have to continue to drop…..line ups will increase….during climate change! Sytem design change would seem mandatory, and needed now…
as a cardiologist I don’t see how one could cream wkim even if you wanted to do. Let’s say you only saw Dr 0’s”easy patients” . Soon Dr O would nort refer you any patients if you picked only certain patients to see, so it wouldn’t work. Also, at the hospital, when on call, you can’t pick to see only the easy patients! You would lose your privileges! So I don’t see how, not that I would want to, someone can “skim” as a specialist.
My point exactly! Well said and with far fewer words. Thanks so much.
Great points, ksy11.
On top of your work becoming harder for the same fee code definition, your fee dollar value has not changed between 1970 – 2010! I tried to insert the graph. Wouldn’t work. Check out figure 9 in this article.
Thanks so much for posting a comment!
The fact you’re writing this blog, bemoans a greater problem in the system. It speaks to the fact that we are all feeling the stressors of diminished resources and inequity and insufficiency in payment.
When times are good, most folks will not be complaining about what they’re getting paid because even the crappy cases, one perceives that they are being remunerated well. During plenty, everyone is happier – a rising tide lifts all boats, as it were.
It’s when times are lousy, when we’re not feeling adequately compensated for all the work we do, when we feel we cannot be paid enough for the sh!t we put up with, then we start to look for ways to game the system – more as a way to relieve our own internal stressors and frustrations and put some value back into the work we do.
Even in a free market system, there will be easy and hard cases that some may prefer over others. But then the market will decide the compensation for each and those that challenge themselves will be remunerated adequately for the extra effort. Those that choose the easy cases may still become incompetent dealing with the harder stuff – but that’s not due to creme skimming – that’s due to the choice you make and your level of comfort seeing certain things. I suspect some of “creme skimming” today is based on comfort and knowledgeability rather than gaming the system.
The fact we’re having this discussion means we’re infighting due to dwindling resources. It means we do not feel the system is fair and we’re not getting the recognition and remuneration we feel our expertise requires. Many of us feel the frustration at the lack of control over our futures. We worry about ourselves and our families. Its during those situations that we start to look out more for number one and the hell with everyone else. If the ship is sinking, I’m grabbing what I can and getting out before we all drown.
Great points, Rob!
I agree: focussing your time on handling cases that match your skills, training, and comfort level is NOT cream skimming. That’s good care. Perhaps I should add that to the post.
Also excellent points on how system austerity drives disfunction.
Thanks so much for reading and posting. Readers love the comment section!
Cheers
Interesting thoughts Shawn,
from practical perspective, as a family MD do you keeps spots thru the day for drop-in’s, and not only for UTIs/colds, but also for kids with lacerations – ? Do you do much stitching/procedures in your office? Because many fam doc’s & even WICs don’t do these procedures nowadays, sending these patients to ER/Urgent Care right away.
And even in many clinics which do the stitches, the MDs are quite reserved to perform them on kids (& even teenagers) because of the pain/needle component & send them to Ped-ER (better equipped/staffed for that, nitric oxide if needed..)
Personally, I am all for efficiency: to do something well, one has to do it a lot. If I don’t do toenail resection often enough, I am gladly referring these patients to a local expert.
From that perspective, I see it reasonable to see the layers from Pharmacists-NPs-WICs to effectively address the “urgent, but not so important/difficult” cases to not overwhelm the FDs/ERs, and let them focus on either “difficult, but not urgent” or “difficult & urgent” – cases. And if the SOCIETY does not see value in these latter services, and the WIC-NPs are better compensated than FDs, the FD/ER physicians will vote with their feet (which might be fair with the limited resources: to cure 100 patients with strep throat vs providing comfort care to 1 patient with CP/Alzheimer).
It’s also not about ideology: luckily, we (still!) work in a market society, and if something needs to be done, the monetary stimuli work better than words: if roster pays well better for the seniors, they would have no “discrimination” from enrollment with FDs.
From professionalism-thesis, we might see another extreme (USA), as the patients usually under-value the “pill-prescribers” vs “interventionists ” , so MDs create a great name by mastering controversial procedures.
Excellent comments, Alexey
As you point out, changing practice patterns and volume create even greater inefficiency in the price fixed environment.
I have spots open most days that I am in the office, but not for procedures. I have spots open for patient service, not because it increases income or efficiency. My group is in the GTA suburban sprawl even though I’m in a rural village as a satellite. As such, our group never makes its access bonus (like most other GTA groups).
I am in a FHO as part of a FHT. I do not find that the procedure codes come close to compensating for even the supplies required for basic laceration repair, let alone the time and effort required to perform the service. I would be paying for the privilege to do most office procedures. “But they are part of the basket,” you say. Indeed…which leads to our initial discussion about price-fixing.
Thanks again for reading and posting a comment!
As a GP, I always keep openings for call ins.. But not for suturing… For me to provide suturing in the office, I need supplies: various kinds of sutures, sterile gauze and dressings, sterile equipment to suture and cut, an autoclave for sterilizing, local anesthetic, sterile gloves, needles and syringes. And if an adult or child comes in with a laceration up to 5 cm, we get renumerated $20 to repair this. And if we’re in a FHO system, we’re expected to do that for free (in the basket). So as a business owner, explain how the up front outlays make this a cost effective service to provide?
Most of our FHG practices are homogenized…the easy cases , so called “ cream”, helping to cover the cost of the more complex “skim” , as was pointed out by Ralph.
Can’t speak for the state subsidized clinics…but the ER’s and WIC’s see a substantial proportion of their homogenized patients simply because of them being available to see their easy and difficult at their patients’ hour of need.
The more expensive NP clinics seem to specialize in the easy “cream” rejecting patients on more than one or two medications….churning them into butter.
The old virtues of medicine were the 3 A’s…. Ability, Amiability and Availability….those practices and institutions that practice the three virtues should not be discouraged from doing so, and certainly not be pilloried in the media and have their billings publicized as if they were capitalistic daemons exploiting the sick and maimed.
As in all professions and other walks of life our profession consists of all types of characters and personalities ….the shysters amongst us are quickly detected, avoided and shunned….we all worked with those who evaded responsibility, palmed off difficult cases, didn’t pull their weight and took advantage of our good will.p, exploiting it.
To expect shysters not to exist in any future health care structure is absurd….indeed in governmental / statist structures they seem to flourish, they may well become medically mediocre as Shawn points out , but they rise nevertheless , shinnying nimbly up that greasy pole.
The free market recognizes the 3 A’s ( to the benefit of all) in a way that statist systems never have or can.
Thanks Andris!
I especially like what you said here: “…those practices and institutions that practice the three virtues should not be discouraged from doing so, and certainly not be pilloried in the media and have their billings publicized as if they were capitalistic daemons exploiting the sick and maimed.”
Medicine was once a noble profession. It has been brought to heel by a hegemonist state. It happens to all professions that the state nationalizes. I find it odd that we find ourselves under the boot of socialism within a “free, democratic, capitalist” country full of citizens who could not care less about the plight of those who provide medical care so long as they get the care they want.
I wax too morose on Easter weekend. Happier days ahead!
Thanks again for taking time to post a comment.
Cheers
Follow up to R Stern…
Of course you are screwed if you start suturing in office…but to Shawns point on the price fixing sytem, by doing this you are being forced to skim inadvertenly…because the ER doc has no choice but to suture for the same lousy pay…the kid excuse is just that: how many GPs suture adults now? WICs are even bigger skimmers, partly due to skills…the ER gets the shaft of ALL specialties , especially in off hours. The morale in ERs is brutal…if ANYTHING is hard , inconvenient or off banking hours, the ER cannot say “no”…
Agreed.. Which is why ERs should be on APP and not FFS..
I wonder what the suturing fee would be out of country.. Probably your bill will include the Physician fee and then all supplies used on top of that. And the supplies will be charged with a customary markup for overhead….
That would be fair..
While doing a locum in northern, rural BC. I often was called upon to suture small wounds as there was no other medical facility within 4 hours of ours. The patient was frequently travelling through to Alaska from the US so we charged the BCMA fee along with extras that included supplies and equipment, the resulting bill being around $200. (BC health care would have paid about $65) Each time we presented the bill the patient was aghast that it was so “cheap” as they had anticipated a much greater charge. We clearly could have doubled the charge and they would have happily paid.
Insane. And we feel the need to defend our $33 fee. This world has become unhinged.
Interesting thread. When my wife was in practice the province to try manage costs put some doctors on salary and there was no incentive for volume. They would see on a good day 8-10 patients a day (had all kinds of time for committee work though Lol). Practice makes perfect and fee for service docs like my wife saw 45-60 patients daily. The salaried docs for example would send their infants coming in with vomitting and/or diarrhea to emerg for a paed to pick them and then the would take care of them as in patients. The veteran fee for service docs frowned upon this. On the other hand after clinics were allowed because about 25% of the community had no doc. Most of it was light duty Rx renewals etc but in practice physicians started seeing their own patients going to the clinics for the same reason because it took so long to see their regular doc. On the other hand, one after clinic that Pat worked at decided to do well woman exams again so many didn’t have a doc and she found some seriously sick women with undiagnosed breast cancer and was able to get them into the system. It seems to strike a balance is a double edged sword.