Salary for Service: the Future Physician Payment Method

With all the talk of health care reform, I have been thinking about how physicians of the future are going to be paid. Obama says that we are going to control costs, and make the system more efficient. (Haven't we always been doing this?) The question I have is what will happen to the providers of care under this revolution. Anyone who reads the criticisms of the current system will see a peppering of the phrase "fee for service" with a quick mention of its detrimental influence on health care costs. "Fee for service encourages physicians to do more things to keep their incomes up."Anyone with common sense can see that this argument is irrefutable. It's just human nature. If you need to make a living, and who doesn't, the temptation will be there to do more things that will generate more income.

The classic argument against this proposal is that physicians are "professionals" and they have the good of the patient as their first duty. This argument doesn't hold a drop of water today. Look at the money making specialty hospitals, look at advertising, look at work schedules of many physicians, look at the way private physicians have turned away from the hospital care of their sick patients and placed them in the hands of the hospitalists. It doesn't take long to see that the standard of caring for OUR patient has fallen short of the ideal of self effacement for the good of the patient. Today, there is a looming question out there about the very existence of "professionalism" in the ranks of medicine.

Controlling costs, that's the most important aim of this health care revolution, and there is one major change that will accomplish this goal: Place all physicians on salary. A salary, no way! It's clear that this is going to happen. Examining the implications will make it clear.

First, this will eliminate the constant drive to do MORE to increase income. It will stop this incentive. Is it desirable for health care reform to "control costs?" You betcha!

Second, it will decrease the number of borderline cases that are done to increase income which drives up the cost of medical care for the nation. It will, to look at it another way, begin a system of surreptitious rationing. Does anyone believe that a sixty hour per week(future work rules) surgeon, on salary, will want to "invest" days and possibly weeks in a elderly patient with numerous co-morbidities and an "ify" prognosis? If I know human nature, it's just not going to happen. The argument to the patient will be," you're just too sick to have this operation." This type of interaction will ration care without anyone knowing.

All of these results are coveted by the health care reformers: less incentive to "produce," and less serious illnesses to pay for. Imagine the cost savings.

Many physicians are on salary already, and they will fall in line easily. It's the private doctors that will cause problems with implementation of this system. No doubt it will be a gradual movement of getting them into a corner and giving them no options when the "answer" of salary will become "apparent." Will it be eliminating the threat of malpractice litigation that will tip the balance? I can't be certain, but it will happen. It's too obvious.

In some ways, it will not be all that bad. Physicians can them relax, move into a different "life style" (a common phrase among younger physicians), and enjoy activities besides medicine. My guess is that the only problem these doctors will face is when they become the patient. By then, it will be too late.

James P. Weaver, M.D.,FACS

American College of Surgeons, Where Are You?

I have been a member of the American College of Surgeons for 30+ years, and I am still disappointed in its ability to defend the profession. Surgeons have lost any control of their work environment, and with that any true sense of a functioning professional. Where is the ACS on this issue?

In a previous article on this blog-A Problem with Patient Safety, Feb. 28, 2009- I explained how "patient safety" has taken a chunk out of professional freedom but that is not the only opportunity that has been squandered by the ACS (American College of Surgeons). In terms of "patient safety" I do not expect to hear a peep out of the ACS over the fact that I have discussed the absence of limits to the regulations over patient safety. In 2004, there were about 70 reports of "wrong site surgery" by the Joint Commission. My guess is that they included even wrong site anaesthetic blocks that were discovered and corrected prior to the surgery. They probably included "near misses." But the critical question is how many surgeries were done in the United States in 2004, and how far are we to go with the regulation of surgeons because of these few mistakes. My guess is that there is a baseline number of "wrong site surgeries" that will be done each year no matter how much control these many organizations impose. I do not condone mistakes, but I don't agree with regulations that are securing jobs for the regulators either. Where is the ACS on this issue?

Another area that illustrates the lack of attention to our professional freedom, is the ACS continued endorsement of regulations that disparage the profession. What does "pay for profession" mean anyway? I thought we were a profession, and that means that we do the best we can ALWAYS! Are they going to pay us more of we preform well? Does that mean that we don't do things well some of the time and we won't be paid as much for those procedures? The ACS should not agree to "pay for performance." Agreeing to this concept is disparaging to the principles of professionalism which the ACS is supposed to represent and protect. Where is the ACS?

Another example of "lack of fortitude" are the recent "should never happen" Medicare rules. Medicare is only looking for reasons not to pay for the work of physicians. Now, I can understand they will not pay for an instrument left in the patient, that makes sense. But what about mediastinal infection after heart surgery? This is clearly an attempt to enter a new area of "denial of payment." Where is the ACS?

I have been involved in hundreds of operations, and infections just happen. The rules are strict, and carefully applied, and IN SPITE of all the precautions, infections occur. It's clear that Medicare has added this exclusion to test our response. The ACS response should have been the same as mine: "Infections can occur in spite of rigorous precautions, and it is unacceptable to include mediastinal infection after heart surgery in this scheme." The ACS should mention the fact that Medicare attempts to withhold payment mainly because of their own budgetary constraints, but history predicts it will not be part of the discussion because the ACS will not bring it up. Where is the ACS?

I could add more, but finally, the Medicare reimbursement system. The ACS should go to Washington and tell them that there is no integrity in this system. The resource based relative value scale does not contain any mention of "value" to the patient. It's value that people pay for when they purchase any product. The RBRVS is a blatant lie, used to control the costs of the promises that the government cannot afford. The ACS should let Washington know that physicians have no trust in the determination of the "value" of their services because the government has a conflict of interest in determining this "value." Currently it has enslaved physicians, and is ruining the profession. It does not look good for the future of patient care under Medicare. Where is the ACS?

Another area that has had "no comment" from the ACS has been re-certification. Physicians are re-certified at all levels these days. The hospitals, the insurance companies, our societies, the state boards, the specialty boards all have a part in re-certification. Isn't that enough? Has the ACS stood up for surgeons, and stated that we have so many organizations and review groups watching us that re-certification is not necessary anymore. Where is the ACS?

American College of Surgeons, please reevaluate, and begin to take an active role in defending our profession.

James P. Weaver, M.D., FACS

A note on Obama's Health Care Summit

Interesting blog from the Cato institute clarifies the make-up of the recent Health Care Summit. According to this blog, there were only those who advocate socialized medicine. Doesn't look good for patients or doctors.

It is good to keep in mind that when the President of Russia, Boris Yeltsin, needed a coronary bypass, the Russian government had to fly a team of surgeons from the United States to get the surgery done. Governments always have expenses that are more important than health care: tanks, guns, bombs, roads, bridges, and more infrastructure. After all, those who are sick are a tiny minority, and most of us believe we will never get sick. If the President of Russia couldn't get a coronary bypass under his own socialized health care system, what will happen to the average person in ours? It's a good question to ask.

I worry about many things in the future of medical care. How will they control costs? What rights will the patients have? What rights will the doctors have? How will talented individuals behave in a system that will surely control their every behavior? I do not believe the "talent" will go into medicine once it's clear that it is government run system. What will happen to research? What will happen to the pharmaceutical industry with the demand for less expensive medicines?

Socialists do not believe in the need for PROFIT in industry. They simply control it. Medical care is a special field. We need talented people to go into it. We need materials to work with, and we need many levels of research to develop the gadgets, and the drugs to help people. Once the power of government begins to take over this system, the creativity will cease. Profit feeds creativity, and government control will squash profit.

I always worry that if I get too far ahead of the crowd in my vision, that everyone will not be able to follow my logic. With this one, it is closer than you think. I don't think I am too far ahead of the thinkers. Government means FORCE, and I am afraid we are about to feel it.

James P. Weaver,M.D., FACS

The Meaning of DNR

I had a provocative conversation last week with a Hospitalist. We talked about the meaning of DNR. I had always thought it meant if the patient stops breathing or goes into cardiac arrest, that one would not try to "bring her back" by external chest massage, electro shock, and iv drugs. The person I was talking with had a different interpretation of this term and stated that, "it means no heroic measures." I have thought about this for quite some time now, and it is a bit disconcerting.


What does "no heroic measures" mean anyway? Who determines what will be "heroic?" Heroic to one might be "necessary" to another. This is of concern, because the person who said this is a recently trained physician, a younger doctor. Is this what they are trained to think these days? I would like to examine this concept more closely.

In a recent post of mine on this blog-The Hospice Threat, January 19, 2009- I discussed my concern with the increasing population of elderly, decreasing dollars for health care, and overworked physicians, that the drive to treat the elderly will diminish. "That old guy has a pretty bad sprained ankle. Maybe we should just let him go,"is a phrase I have used to illustrate this probable future shift in physician behavior.

It seems to me that "no heroic measures" potentially is a much broader interpretation of the DNR concept. Is it heroic to treat a urinary tract infection in a 85 year old patient who has had a previous stroke and is hemiparetic? And how about using antibiotics to treat pneumonia in a renal failure patient with a previous amputation, cardiac disease, and a previous stroke, is that heroic? The problem with "no heroic measures" is that it is vague enough that it opens the door to RATIONING. This rationing, unfortunately, will be used in a "final" sense.

We don't like to say the "R"word, but it isgoing to happen; the question is how? Will certain services be denied? Will certain services be prohibited? My guess is that certain things will not be paid for, and others will not be available. The critical issue is that the behavior of physicians should not be influenced by societal pressures. I'm afraid that, in the future, the societal influences on physicians behavior will be covert and subtle. Physicians will just not do what they did twenty years ago to save an elderly patient.

I see this different understanding of DNR as another wedge into the physician-patient relationship, with the potential to weaken the physician's classical obligation for the care of the patient. This is yet another example of forces diminishing our Professionalism. With the financial pressures on medical care, this is just another brick in the foundation of rationing.


James P. Weaver, M.D.,FACS