Recently I was discussing how surgeons will tell you whether they think they should operate on you AND then get paid to operate, and I began thinking more and more about the concept of fee for service in medicine. I am disturbed by the fact that the same physician gets paid for performing a procedure, when they are the one that decided the procedure was needed. In other words, it would strike me as strange if I went to a painter who charges 500$ per room painted to ask him if I needed to repaint some rooms in my house. Wouldn’t it be strange if the SAME person decided 1) if you needed rooms painted, 2) told you that is what they do and they will do the service, and 3) they did it for a fee you didn’t really know about until later. In my view, I would like an independent consultant to determine the need for the paint (my family – “should we paint this room?”), a separate company to do the painting, and the price to be agreed upon before starting (and having the option of using a cheaper provider).
Because many of you are medical people, I am positive I am stepping on more than a few toes here. But aren’t we setting up physicians for unethical behavior when we pay them much more for doing procedures than thorough examinations, and we financially reward them for doing as many procedures as possible? If you are a cardiologist and you get paid 3,000$ per catheterization and 80$ for talking to a patient and doing a stress test, why would you NOT take any patient you could to the lab for a cath- Especially if the cath took less time. Now you can move patients through and make lots of money. And if you have a family money is a good thing. You’ll have a better chance of protecting your family in the case of emergencies and a better chance of providing a stimulating environment for children to grow up in. Also, having money will give you a better chance of sending them to study whatever they wish to pursue in life. Making a living is a good thing.
One problem is people don’t like to talk about money. But doctoring IS a profession, and a highly regarded one. Not only this, but the best of the best go into it, and part of this is that they are well-respected and adequately compensated for their considerable gifts, talents, and sacrifices. In my view, paying doctors less is not an option. As it is, they spend a lot of money and time in training during the best years of their lives. Many of the doctors who have devoted their lives to insane working hours could devote that time and energy in the business world and make MUCH more. But they don’t. Lowering income much will only lead to our beginning to lose some of the best and brightest.
But why must we reward doctors that do many so procedures and not necessarily needed/cost effective ones? Why can’t we figure out a way to salary doctors, so they are free to practice good medicine as they see fit? Why can’t we create a system in which the reward of good medicine is a higher salary? In other words, if you were rewarded at your engineering firm for the number of jobs you did, you would plow through them with little regard for quality. (Or with an adequate understanding of the “lowest level” work you can get away with legally. Of course, you would also be cognizant of your market and whether you may lose customers for this type of low level work. In medicine, you won’t lose customers because there is a shortage of doctors and few patients are given a choice as to which doctor they can see.) However, if the quality of your work was being analyzed, and your pay was determined by how good your work was, you would slow down and do your absolute best. Especially if this meant that your future salary would be in part determined by the quality of patient care you were giving.
Doctoring is set up now to encourage unethical behavior. Luckily, some of our most altruistic men and women become doctors and resist this temptation to practice bad medicine their whole career. The problem is the system. We need to fix it before we taint medicine forever. How far away are we from an expose on this topic that hits the New York Times and turns off a whole generation to scientifically-grounded medicine? How far away are we from the public distrusting everything about doctors due to something like this? We must fix it before someone fixes it for us. If you’re a doctor, I’m not sure why you are still reading this; shouldn’t you be doing a procedure?
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2 comments:
Great post. I also hate the "business of medicine".
Now, today I was just thinking about this... there are a lot of private hospitals and private physicians out there that are only interested in the business of medicine. I was immediately reminded of the "outside hospital" joke. Outside hospital is any random hospital, that usually transfers the sick (and expensive) patients to the university or county (medicare funded, or free care) hospitals. (check out the joke here: http://www.youtube.com/watch?v=xskFo75Wdhs )
A sad example of this: while on call, we received a delirious and very sick elderly man. Outside hospital sent a brief history of what happened to the patient. Apparently he was in a nursing home, was noted to "act different" and sent to the ER, where labs were drawn and it was obvious he had a sever infection somewhere that caused this acute state of delirium. We received the transfer, had only this info and some nursing notes from the outside hosp, and couldnt get any history from the patient because of his delirium.
So... as soon as the sun came up (he came in at 3am) I tried calling his nursing home or family member. Turns out the entire history from the hospital was wrong (he wasnt even from a nursing home!)... long story short, because we called the family we were able to realize what was going on with the patient. Regardless, the patient died hours later.
Why didnt he receive adequate treatment at outside hospital? Too sick, too expensive, too elderly. Could this patient survive a little longer? I know he would've died soon (complicated cancer), but definitely not that day if he had the care he needed at outside hospital (vs a lengthy transfer and delayed care). Outside hospital didnt even bother to take adequate history of the patient. Elderly, probably uninsured, probably poor, NOT LUCRATIVE. That is the business of medicine.
Matt,
In an ideal world, all Docs would abide by Oath they took when graduating medical school. Which basically says, 'do the best for your patient regardless of compensation.'
Keeping this in mind, a surgeon would only recommend a patient have something done if they felt that it was the BEST thing for the patient. A cardiologist should be current enough on the latest literature to know the stipulations that would direct whether a patient gets a stress echo vs a catheterization. There are grey zones, where a patient might fall right in the middle...then it would be up to professional discretion.
Are there money hungry procedure doing Docs? Yes, I'm sure there are. But I would like to give my profession a bit more credit, and hope that this is more of an exception rather than a rule.
I think that you will feel differently in a few years.
Kev
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