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.