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

A Problem with Patient Safety?

Don't think I'm about to write that patient safety is the best thing that ever happened to medical care. I'm not. I think it might be useful sometimes, and is occasionally a reasonable addition to procedures in medicine, but the problem with "patient safety" is that there are NO LIMITS to its implementation.

All this patient safety began around the time of the publication of the book, To Err is Human. It was published by the Institute of Medicine in 1999. There had been rumblings about safety before that, but that book began the major onslaught of regulations. JACHO, CMS, state agencies, leap frog, medical board organizations, insurance companies and others, too many to count,began to apply their own regulations to support the growing idea that the doctors were dangerous and needed to be controlled! After all, doctors kill over 100,000 patients/yr. with mistakes.

First of all, I'm not certain that figure is accurate. I have been in medicine for over 30 years, and I can barely remember deaths caused by errors. Is giving the "wrong" antibiotic prior to culture results a mistake; is an incisional hernia a mistake; is an infection after surgery a mistake (even in a malnourished patient); is a heart attack after a below knee amputation a mistake? These numbers added up, and fed the final conclusion of 100,000. These numbers are based on research done in the 1980s to discover why there were so many malpractice suits, and I have questions about these statistics. It sounded good, and this conclusion opened the door to control and regulation of doctors with no limits. After all, who can speak up against "patient safety?" Not me!
But there is problem with this crusade. "Outsiders" have been given authority to manipulate and control all aspects of physician behavior to the extent that any semblance of professionalism is being decimated. Professionalism includes the concept of PROFESSIONAL FREEDOM, and this has disappeared in medical practice. CMS demands some of these rules because of payment constraints, but they all jumble together to control the day to day behavior of physicians. Do they really believe we are trying to make errors? It just happens decisions in medical care are difficult, and that's why we used to be paid well for our work.

The words we use in our "private patient charts," the details of behavior in the operating room, the "time out," the concept of patient consult versus evaluation, instrument and sponge counts on cases with incisions only 3 centimeters long; updating a physical exam prior to surgery, re-dating the operative request;signing verbal orders within 24hours, dictating operative notes within 24 hours, and not to mention the continued devaluation of our services through reimbursement reduction, are just a few examples of the ever increasing infringement on professional liberty that physicians are forced to endure. Are these checks useful? Maybe some of them, we don't truly know. One thing, however, is for sure: they are selecting a certain type of physician who will practice in the future in this oppressive environment. This "new" doctor will be the type who will not live a life for medicine or for the patients. Medicine will become a job, a supplement to a "lifestyle" which offers time off, reasonable payment, time for family, and time for other "more important" activities. As long as these doctors follow the RULES, and stay under the radar of the regulators, they can continue to work at their job. Fortunately, it was not a job in the past, it was a profession.

Surgeons are now required to do a "time out" prior to operation. I have never operated on the wrong patient or wrong side in 30 years. But we are now required to mark the site prior to surgery, have the request signed before surgery, and discuss the site of surgery before we do it. I am surprised that we are not required to turn around three times after the "time out" and do it again to make sure we have the right patient!

If the specialty organizations-American College of Surgeons, American College of Physicians, American College of Cardiology, etc.- do not begin to speak up against the continued oppression of physicians, and begin to demand some reasonable limits to these oppressive regulations, I fear the patients of the future will be treated by physicians who are not particularly concerned or motivated to get the best for each patient. These new physicians will be a "physician bureaucrat" who is enforcing the RULES of "the system." I do not believe this is a bargain society wants. There can be no profession without "professional liberty." Professional behavior and motivation depends upon it.

James P. Weaver, M.D.