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