Should doctors be paid for performance?

[PrincessFiona]

I thought this was an interesting article:

http://online.wsj.com/news/articles/...54432476458370


I have mixed feelings about this. I know several internists who are so upset with their diabetes patients that they are simply making it more difficult for them to get appointments. Non-compliance with diet/exercise (which the physician has no control over) leads to poor A1C numbers and no financial rewards, so they don't have the patience anymore for these patients. It seems that patient satisfaction surveys have become a norm in evaluating physician performance and that because of this, some doctors feel pressured to just give the patient what they want instead of practicing good medicine (ie handing out unnecessary antibiotics instead of sending the patient home empty-handed).

Here, part of this whole mix (and I'm not sure how it fits in) is a reward to physicians that have patients sign up for electronic communication (MyChart). I know a physician who has laid it all on the line with her patients "sign up or see someone else" She basically said she's not willing to take a paycut because her patients won't sign up. I understand this even though it seems harsh. This is a tough line though because many elderly patients in particular on not comfortable with the internet or electronic communication.

How do you feel about this?

Kris

[Vanquisher]

It's fucking ridiculous. No, physicians should not be payed based on performance. I feel the same way about teachers. Too many variables are beyond your control.

[HouseofWool]

The signing up for patient portals is a CMS thing and I fucking hate it. No way should a doc be penalized because their patients are luddites, yet that is what is happening with us unless I can find a way to "fix" 100+ charts in the next 2-3 days.

[SuzySunshine]

Not until they can figure out a way to do it evenly and for some patients/diseases nope because like others have said there is only so much the doc can do. DH just went back through two years of his patients for ONE type of procedure because he was looking for a stat to give a talk, he realized several never even came back for follow-ups. Patients who had a significant tumor taken from a significant part of their brain just never showed up again, how is that his fault? Now that he's noticed he's getting on his staff to follow-up with them and try to get them to come in but why should he be penalized for that?

When Obama was first elected and his healthcare plan was being created the then CEO of Mayo played a role in the beginning of getting pay for performance as an important part but as it became obvious to him that the outcomes weren't going to be measured as they needed to be he bowed out. I just don't know how it would be done.

[Phoebe]

I
I think paying on performance isn't right. Indiana rates their teachers on student performance. Stupid.

[SoonerTexan]

Haven't read the article, but how on earth would it work for a specialty like Radiology?

[PrincessFiona]

Patient wait times, patient recall rates for diagnostics like mammography, referring physician satisfaction, possibly diagnostic accuracy.

No specialty will go untouched.

[scrub-jay]

Should doctors be paid for performance?

It's a ridiculous system that replaces intrinsic motivators and will likely decrease quality.

[KlynK]

It's fucking ridiculous. No, physicians should not be payed based on performance. I feel the same way about teachers. Too many variables are beyond your control.

That, 100%!!


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[ladymoreta]

I agree. If performance is a problem, it should be taken care of by the hospital/supervisors. (In the case of mistakes being made or patients making legitimate complaints about a doctor) This is just a stupid excuse to cut payments for doctors who aren't really having problems.

[Flynn]

My comments are based on procedure based specialities. I have no background or experience (and therefore am not commenting) with clinical doctors.

I disagree with almost everything that's been said. Doctors are NOTORIOUS for NOT governing themselves. An older surgeon with hands that are unsteady can operate for YEARS without anyone saying anything AND have high mortality rates. WHY? Because one or two words from an older doc about how he's being "shoved out of the practice unfairly" and younger docs in the practice have their referrals dry up. The practice suffers. Everyone knows the higher specialities pay for ALL OTHER FORMS OF MEDICINE. Hospitals can't survive on clinical docs alone.

Administrators are petrified of "calling out" an unsafe surgeon for fear of malpractice claims flooding their office. They sugar coat why surgeons "move on" and hope nobody blames them. It's quite common. For younger surgeons this is form of residency all over again. Keep your head down, don't report ANYTHING and hope Doctor Death retires soon.

Additionally, if docs can be paid for production -- then ethically there has be a quality or what I prefer to call a "VALUE" component to their pay. The tough part is finding the right formula to read the data which brings up another issue -- DATA. Nationally, Cardiac statistics are kept and everyone has access to them which I think is pretty rare for other surgical specialities. The governing body of Cardiac (I forget the name) gives out one, two or three stars to programs (not individual surgeons) based on these statistics every year (this is pretty new). Being a three star program is a big deal and very difficult to achieve but it DOES mean something. DH has to go before the board of directors for his hospital today to explain why their program fell from three to two stars.

DH has a quality component to his contract that is in his "bonus" part of his pay. It's based on of course mortality -- but also time in hospital, and how follow ups go and are there complications to name a few areas. If a patient does not come back for follow ups they are tracked down and spoken to OR a family member is found. If the patient has died since the operation, a person in the office finds out why and all of these statistics are compiled. DH's practice has the second sickest (highest risk) pool of patients in the state and these statistics factor into his quality component so he and his fellow surgeons are not penalized for having the sickest patients.

Quality HAS to be a component in the future of medicine and within that umbrella there has to be VALUE.
I strongly recommend reading: Redefining Health Care -- Creating Value Based Competition on Results by Michael E. Porter

Has anyone read it? My DH is perplexed and fascinated with the daunting task of overhauling medicine in the future. He reads everything on the topic and this book really intrigued him. I have read most of it but I admit it got a bit LONG winded for me. I read enough to get the main point and be able to understand what DH was talking about.

"The U.S. health care system is in crisis. At stake are the quality of care for millions of Americans and the financial well-being of individuals and employers squeezed by skyrocketing premiums—not to mention the stability of state and federal government budgets.

In Redefining Health Care, internationally renowned strategy expert Michael Porter and innovation expert Elizabeth Teisberg reveal the underlying—and largely overlooked—causes of the problem, and provide a powerful prescription for change.

The authors argue that competition currently takes place at the wrong level—among health plans, networks, and hospitals—rather than where it matters most, in the diagnosis, treatment, and prevention of specific health conditions. Participants in the system accumulate bargaining power and shift costs in a zero-sum competition, rather than creating value for patients. Based on an exhaustive study of the U.S. health care system, Redefining Health Care lays out a breakthrough framework for redefining the way competition in health care delivery takes place—and unleashing stunning improvements in quality and efficiency.

With specific recommendations for hospitals, doctors, health plans, employers, and policy makers, this book shows how to move health care toward positive-sum competition that delivers lasting benefits for all."

[Vanquisher]

Yes, but that's not how insurance companies measure quality. They measure complete bullshit.

If you're paid based on your mortality rate alone, what's to stop a surgeon from cherry-picking the healthiest patients.

No, doctors should not be paid based on performance.

[Thirteen]

I'm not a specialist, but I will say that Press Ganey scores are a Catch 22. Most patients feel satisfied if they leave with some form of prescription - they are all too happy to tell everyone what a great doctor they have.
Except... Many illnesses are viral. Abx won't help.
Steroid shots simply alleviate inflammatory sx, but actually lower the body's immuno response to fight infx.

If someone like DH says "No, that's not warranted.", then patients have the right to grade his performance based on not giving them what they feel they needed, essentially.

So, how to treat? Do you give people what they want, have good scores, and keep your system happy? Or, do you practice evidence-based medicine, piss off a few people, and perhaps suffer in scoring (which, is also directly related to pay and bonus options).

Primary care can't win. I agree there should/needs to be self-governing, but I believe it should be from inside each system, like a quality alliance that is comprised of both physicians (multiple areas of discipline represented), and a few suits.

Right now, it's just a mess.


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[Flynn]

Yes, but that's not how insurance companies measure quality. They measure complete bullshit.

If you're paid based on your mortality rate alone, what's to stop a surgeon from cherry-picking the healthiest patients.

No, doctors should not be paid based on performance.

I am not in favor of insurance companies getting involved in this. I am saying that doctors being paid from the hospital they work for (or hospitals) should have a quality component to their bonus in their salary. Some surgeons will operate on ANYONE because they are paid for production. Hospitals make money on procedures regardless of whether they die. That's unethical.

[Vanquisher]

Right. But the fact is, insurance companies are the payors, not hospitals. Not all physicians, a good number, are not employed by hospitals at all.