It seems to be the season of healthcare reform. The news is buzzing all about universal healthcare and health insurance. However, those are not the only contributers for healthcare reform. Simple things such as how you pay your doctor can make a huge impact on healthcare in America. In January-February, Tim Foley author for the Universal Healthcare cause on Change.org wrote a trilogy of articles with the common theme, “How Should Your Doctor Be Paid?”
In this series of articles he presented three ways:
Fee For Service-
– The question of how physicians, nurses, hospitals and other health care workers should be compensated for health care has been cut-and-dried for most of the history of modern medicine. Doctors were paid a fee for a service. Need to get a broken arm set in a cast? That costs X. Need to have a mole removed? That costs Y. But despite the hallowed glint of tradition and custom, the times have clearly changed. We can’t ignore the unintended negative consequences of fee-for-service in our Monopoly Money health care system, and we’ve been confronted with too many other competing ideas on how to pay for health care….
The basic concept of Fee-For-Service is that patients play the role of consumers, and doctors the producers. The problem with this, is that healthcare should not be a simple business transaction. Corruption is compatible with this. This gives doctors the monetary incentive of providing unnecessary procedures for patients, and charging for them regardless of the results. If it gets to that point, it will be difficult to distinguish a doctor from a pharmacist. A common example of fee-for-service are family doctors. The length of a visit does not make a difference in fee-for-service, which leaves doctors with an incentive to visit more patients in a short time. The same can be said for appointments. We’ve all been to the doctors office and had to wait a while. 5 minutes, 15, 30, 45, even an hour? It isn’t a surprise. Doctors may rush appointments, in order to schedule more appointments in a day. The logic of Fee-For-Service is simple: Provide more services to more people in a single day, and get more money. It becomes a monetary incentive to treat patients quickly, instead of putting the time an effort into a patient for results.
Episodes of Care-
The presidential campaign of 2008 wasn’t that long ago, and one of the areas of health care that John McCain reliably talked about was paying doctors based on “outcomes,” though he was never specific on quite what he meant by that. Barack Obama also campaigned on “aligning incentives for excellence” – again, a little hazy on what that meant or how you get there. To patients, these seem unobjectionable because they fit in the mindset of “I got better, so my doctor should get paid.” However, it scares the bejeesus out of the doctors I know….
Episodes of Care is parallel to Teacher’s Merit pay. The better the results of a patient, the better the pay for the doctor. In theory, (just as merit pay for teachers) this seems the most logical. You would be rewarding your doctor for their good service. However, as Foley says, “it scares the bejeesus out of the doctors…”
While doctors would be paid more for better results, they would also be paid less for unsuccesful results in patients. While it could be a matter of how “good” a doctor is, episodes of cares leaves most of the power of a doctor’s pay in the patient’s hands. Clients would pay an annual sum of money to the doctor, and would only be expected to come in once or twice a year for a check-up. The rest of the money would be discretional for the doctors. However, patients who become ill have to see the doctor more often throughout the year, and ultimately means that the doctor would have less profit. This leads to “cherry-picking” healthy patients.
It also leads to the other issue of patients just not listening to their doctors. A doctor can advice a patient to eat healthier, exercisee regularly, take a specific medicine, but the patient has the freedom of refusing the advice. The patient will obviously not become any healthier, and may even require more visits with the doctor which means less pocket change for the doctor.
The big question is, as William put it, “What’s wrong with doctors being paid a salary? It’s a system that has long been used in the military, and is used in HMO-owned clinics. For the docs, it means they can really just focus on what most of them love to do–healing the sick, and keeping the well, well. Let others handle the administrivia.”
There are a number of contexts in which doctors are salaried here in the U.S. and yes, it tends to work out extremely well for them. As William mentioned, there are HMOs who provide both the care and the insurance…
When doctors are paid by salaries, they can focus on their patients more and overall, put a better effort into treating them. Unlike fee-for-service, they do not have an incentive to squeeze more patients in a single day, or rush appointments, and unlike episodes of care, they do not have to worry about cherry picking patients for more profit. The only doctors paid by salary are from the military, Department of Defense, and NGO’s which include Medicare. One can always argue that poor doctors would be recieving pay anyway for their poor work, but salaries do not work black-and-white like that. Foley explains that in his last, “How Should Your Doctor Be Paid” article.
Healthcare reform should follow the curtails of Medicare and Medicaid. The idea of universal healthcare is to expand social services for people who cannot afford to pay for hospital expenses. Fee-For-Service is how doctors are typically paid. It’s unreliable and unaffordable for people without insurance. For these people they have to live without hospital visits, and perhaps live more susceptible to ilnesses and are oblivious to their own health. As discussed earlier in this post, people who do not see doctors regularily tend to need to see doctors more often. Episode of Care will ultimately lead doctors to cherry-pick healthy patients, which are more often than not middle and upper class, which would result in neglecting the lower class who tend to be in the unhealthy bracket.
If Obama’s Universal Healthcare bill passes, this would mean that the public have access to health insurance. Doctors won’t have to discriminate against their patients, and will not be driven by profit to see more patients and cheat them by providing unnecessary procedures. At the end of the day, (or should I say month?) They will be given the same amount of money as any other day, and can hopefully give the attention their patients need to them. Doctors can focus on their job, and not their wallet.
As for the doctors who are driven by monetary incentive, they can always become private doctors for the people who can afford them.
In the end, the idea is to be able to eliminate corruption within the healthcare spectrum, and the method of paying salaries to doctors has been proven to be the most succesful. Afterall, President Obama wasn’t lying when he said he has the best healthcare service in America.