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    Sunday, July 29, 2007

    The Other Shoe Drops: We (as in we all in the medical profession) knew this would be coming:

    These economists, some of whom are also doctors, say the partisan fight over insurers and drug makers is a distraction from a bigger problem: the relatively high salaries paid to American doctors, and even more importantly, the way they are compensated.

    Currently doctors get paid for piece work. They get paid by the patient, or by the procedure. Even doctors who are paid a salary by someone else get paid by the piece. They're just sheltered from that reality because it's the someone else who gets the reimbursement, hoping that the amount the doctor generates will be more than what they pay him.

    The gist of the op-ed is that all doctors should be paid by salary with bonuses if their patients follow their advice. Now there's someone who lives in fantasy more than reality. The problem with a flat salary is that there's no incentive to maximize work. Show me a salaried doctor (without a productivity bonus) and I'll show you one who believes strongly in his right to get home by 5PM, regardless of medical problems coming through the door, or over the phones, that day. This translates into doctors who send acute problems that could be handled in the office to the emergency room to avoid hampering their own schedules, doctors who schedule longer appointments, or block off time to allow extra time for paperwork during the day. The solution to those problems is usually to hire an administrator to try to make the doctor work harder.

    The "paid by the patient" system actually makes the most sense. There's an incentive there for the doctor to work as efficiently as possible to see the maximum number of patients possible. The drawback is that some doctors overwork themselves and their schedules to maximize profits, but my sense is that there are actually few who do that. Most people strike a balance between efficiency and good care. They come to realize their limits and the limites of patient safety. They do it better than an administrator, who has no idea of how many patients a doctor is capable of safely seeing a day, but who is paid to make sure salaried doctors see more patients.

    And check out this parting comment from the op-ed:

    But Dr. Goldman of RAND said that doctors are misleading themselves if they think the current system serves patients’ needs.

    For example, if a diabetic patient visits a doctor, he said, "the doctor is paid to check his feet, they’re paid to check his eyes; they’re not paid to make sure he goes out and exercises and really, that may be the most important thing."

    "The whole health-care system is set up to pay for services that are rendered," he said, "when the patient, and society, is interested in health."

    I don't think you could pay me enough to follow all of my patients home and beat them into submission.

    posted by Sydney on 7/29/2007 11:07:00 AM 3 comments


    "Paid by the patient" is exactly the good intention that paved the way to HMO hell.

    By Anonymous Anonymous, at 3:24 PM  

    Such remarkable ignorance, insensitivity and severe lack of any sense of professionalism...

    I'm on salary, 7PM, 10 hours (and counting).

    By Anonymous Dr Dino, at 6:17 PM  


    The HMO "paid by the patient" capitation system isn't the same. That's closer to a salary system since the doctor gets paid the same whether or not he sees the patients. In fact, he has an incentive to keep his patients out of the office, to reduce overhead. The current system may be better termed "paid by the visit."

    Dr. Dino,

    7PM, 10 hours, and more than bit grouchy. You are the exception. But I have a sneaky feeling that you have a boss somewhere who is constantly urging you to see more patients. Wouldn't you be happier working on a productivity basis and knowing that you are reaping what you sow?

    By Blogger sydney, at 10:31 PM  

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