Doc pay

"You can't end fee-for-service by signing a piece of legislation."

Sure you can.

Just saying.

One area that hasn't yet been explored is lowering doctor's costs to allow decreases in fees without major loss in real income.

For example, med school will run you about $100k in debt. Servicing that not only requires some heavy fee generation early on in life, but also prompts people to pick high pay specialties over primary care.

A Federal malpractice insurance program could also help. Average malpractice insurance rates (using PA's averages, since PA is about average) run about $6-11k for internal medicine, $28-50k for general surgery, and $64k for OBGYNs. Cutting those premiums would allow us to pay much less for services without having to get into an all-out war with the AMA over doctor's incomes, since real incomes wouldn't change.

great great ideas.

Too bad the AMA would disown this doctor immediately.

Similarly, Medicare needs help finding fraud. Any staffing to help root out stupid care that can clearly be discouraged would be cost-saving.

this has been my little pet peeve all along. at $60 Billion a year and a miniscule budget for fraud prevention you'd think they'd have a little more sense than that. When crack dealers in Miami are getting into medicare fraud instead of drug dealing because its less hassle for them, pays more that should tell you something.

Doctors' pay is a general, broad and vague term. Step 1: Take a look at the salaries of interns and residents. Then, take a look at what their salaries have been for the last ten years. Income disparities are regional and increases likely reflect cost-of-living increases. Step 2: Take a look at doctors' incomes in various specialties. Then, take a look at those incomes over the past ten years. There have been no increases. This is completely separate from the fact that some doctors own their own imaging equipment, or develop medical devices, or help create new pharmaceuticals and, thus, earn additional income from these enterprises.

It is absolutely true that there is an income disparity between primary care physicians and specialists. It would be quite easy to change this disparity in the health care legislation being considered, but, again, the political forces get in the way of it.

It should also be pointed out that most doctors are not members of the AMA. Most doctors are members of the organization that represents the field in which they practice, eg emergency medicine, anesthesiology, psychiatry, pediatrics, etc. The problem is that most people outside of medicine have only heard of the AMA, thus, a conservative piece of legislation backed by the AMA seems to most people to be the good house-keeping seal of approval, regardless of the fact that it represents a minority of practicing physicians.

Although salary-based pay for physicians certainly is an effective method for controlling costs (that’s how I’m paid) and would eliminate the disincentives that come from a fee-for-service method, it would be virtually impossible to convert the US health care system to that structure. Most MDs in private practice essentially work for themselves or as part of a small group, and therefore have nobody who employs them or who could give them a salary.

One major problem, pointed out by others, is that procedures are often reimbursed at a much higher rate than non-procedural care. Procedures have an amplifying effect: if I operate on somebody, then I also generate costs for the OR, the anesthesiologist, the equipment manufacturer, etc. Reimburse structure definitely affects decision-making.

I like to say that no ethical physician would let profit decide how he treats a patient, but no honest physician would deny it has an effect on how he practices.

And fee-for-service seems to work well in many other countries that have less expensive and better health care systems, e.g. France, Germany, Japan, etc. The key difference is that the fees paid to providers in those countries are uniform and low. As a result the doctors and the hospitals make less money. The insurance companies also are mostly not-for-profit when it comes to basic health care. If we want to control costs, that’s where we need to go. But it will involve a huge battle against powerful special interests. So far, patients have not shown an interest in engaging in that battle.

rlplant is exactly right. I too receive a essentially a salary with a production bonus (at least,in better years we get a bonus!)

Although there are a few docs who make ungodly amounts of money, for the most part U.S. docs with respect to salaries in the U.S. make about what European and Canadian docs make for the same specialties with respect to salaries in their respective countries. It's just that there are a lot more high-priced specialists in the U.S. In fact, there are so many specialists that they wind up performing a lot of primary care functions -- at a higher price.

Specialists who do primary care functions usually only do those primary care functions that correspond to their specialty. As a result, some one who receives primary care mostly through specialists receives fragmented care from multiple providers where a properly trained generalist could provide care for multiple conditions much more efficiently.

Training is, IMHO, a bigger part of the problem than salary vs. fee-for-service. In the U.S. we train more specialists than Europe. We also do a substantially crappier job of training generalists. Although it is a fond belief on this blog that U.S. docs receive more years of training than their European counterparts, that's only partially true. Both sides of the pond are required to take 2 years of pre-med classes (the same requirements +/-) and 4 years of medical school. The divide comes at the post-graduate medical training. Generalists in Europe receive training that is mostly oriented to outpatient medicine. "Specialists" in Europe generally do a year of academic research, then go straight into their specialty field. In the U.S. most specialists first do 3 years of inpatient generalist training, then go on to do specialty training. Many generalists do not get much in the way of outpatient training. Obviously there is some overlap in caring for inpatient and outpatient pneumonia, for instance, but there are often some significant management differences. Generalists do not receive much respect at the training level and then get paid substantially less than specialists. It's not surprising that most young MDs/PAs/NPs prefer to go into specialty care.

When I was working for salaried medical group, I used to get mad that we were paying a neurosurgeon $500K a year mostly to sit on his butt and play solitaire. "Better than paying him to operate," was someone's answer.

I had occasion to spend 12 hours -- not sick myself -- in the ER of a major academic med center the other day. At least one third of what was going on around me was wasted activity caused mostly by absence of computerized record keeping. Described this in detail at:
http://bit.ly/ER_waste

As a test, couldn't Medicare simply start implementing some of these cost saving ideas without legislation? What can Medicare decide to do on its own and what requires legislation?

I know for instance that at my hospital we already have to justify the use of Epogen/Procrit (a multi-billion dollar red blood cell stimulating drug) with certain lab levels in order to get payed by Medicare. Because its simpler we therefore justify to all insurances. This kind of thing could be expanded greatly.

Please someone debunk this if I'm wrong.