tag:blogger.com,1999:blog-30499448.post7579595930402738666..comments2024-02-18T13:53:30.168-08:00Comments on Surgeonsblog: Times TwoSid Schwabhttp://www.blogger.com/profile/14182853083503404098noreply@blogger.comBlogger16125tag:blogger.com,1999:blog-30499448.post-80176654208129401752007-08-08T17:44:00.000-07:002007-08-08T17:44:00.000-07:00Bonuses based on patients' health? The bean-counte...Bonuses based on patients' health? The bean-counters look up simple guidelines & try to extrapolate quality of physician care based on claims-data ALREADY.<BR/><BR/>I wrote rxs for my father-in-law once for his glucophage, since he moved & didn't hook up with a new MD (mistake, I admit). Thereafter I got regular contacts from "Active Health Management" asking me to copy & fax sections of the chart where I documented eye exams, HbA1c values, urine microalbumin, nutritional counselling, etc.<BR/><BR/>So let's say it WASN'T my father-in-law, but rather was my patient, and he/she simply didn't follow my instructions, fill meds, get labs, follow-up, etc.? Do I get dinged for that? That is the essence of P4P.<BR/><BR/>And by the way, all of that extra paperwork is totally unreimbursed.<BR/><BR/>The message is clear - simply don't take on complicated patients (e.g. diabetes, cancer, heart disease, geriatric, etc). <BR/>I echo the prior sentiments, & just hope I don't get sick; otherwise thankfully I went to med school & residency for umpteen years. So much for everyone else.Happymanhttps://www.blogger.com/profile/08682200319832416757noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-30513924741532434862007-08-06T06:27:00.000-07:002007-08-06T06:27:00.000-07:00Sid,Did you catch the letter from economist Uwe Re...Sid,<BR/><BR/>Did you catch the letter from economist Uwe Reinhardt in the Sunday NYT yesterday about the article you refer to?<BR/><BR/>I mention this (and you) today over on Plastic Surgery 101.<BR/><BR/>http://plasticsurgery101.blogspot.com/<BR/><BR/>Cheers!<BR/>RobDr. Rob Oliver Jr.https://www.blogger.com/profile/09059882318849767896noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-21972634806980969992007-08-04T18:26:00.000-07:002007-08-04T18:26:00.000-07:00I'm willing to bet we'll see an influx of capable,...<B>I'm willing to bet we'll see an influx of capable, smart, committed young physicians who are utterly content to accept a salary, rather than unlimited wealth, in exchange for a controllable schedule and a 50-hour workweek. </B><BR/><BR/>I doubt it. From what I hear, residency smacks all Utopian thought right out of one's head. People used to say this about teachers, too, and you don't have to look far to see their contract negotiations are a continuing source of angst.<BR/><BR/> <B>The ones who drop out because they can no longer overtime their way to a Porsche Carrera GT will be replaced (sooner or later) by 40-year-old women who seize the opportunity to both save lives AND see more of their kids. </B><BR/><BR/>You seem to mistake a person willing to work for less as being the best choice. Not in my world. I'm all for a sale, but not when it comes to medical care. Benevolence only goes so far and it will never usurp Man's natural desire to exceed and be properly compensated. The only way to get the best is to pay for it. It's in our genetics.Lynn Pricehttps://www.blogger.com/profile/02958402288888144904noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-51432598197430062812007-08-02T08:29:00.000-07:002007-08-02T08:29:00.000-07:00supply and demand. but the time and effort put int...supply and demand. but the time and effort put into becoming a doctor, reflected often in the astronomical student loans may make it not worth anyone's while. i like moe's philanthropic sentiments but i don't think there are enough people willing to put themselves through so much just to have the right to save lives. besides these women he talks about seeing their children, what happens when some selfish patient attempts to die after hours? <BR/><BR/>especially surgeons. in our country we have a growing shortage of them. who wants to study for 15 years to end up doing this type of work for dropping wages and massive student loans. sorry, especially in surgery these women will not suddenly appear to fill the void. i agree with sid. my basic plan is to not get sick when i'm older.Bongihttps://www.blogger.com/profile/12918640034313468627noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-32537220901980707832007-08-01T21:52:00.000-07:002007-08-01T21:52:00.000-07:00SO, no question, financial incentives and disincen...SO, no question, financial incentives and disincentives have an effect;that's why a market based system works. As to the assertion that physician supply will rise to meet demand regardless of payment, that flys in the face of market theory, and is belied in the UK; just review the "Say goodbye to doctor" post (july 25) in UK blog doctor. Heck, we already have a payment based supply shortage in primary care in the Southwest. Once reimbursement gets low enough, the market will find its own level; if prices are regulated by the government without recourse, there will arise a "black market" in healthcare, just like there are black markets everywhere there are government price controls. Black market is one way to characterize the rise of "concierge medicine" by the way. It just isn't illegal (yet).<BR/><BR/>RATIONING, of course, is the underlying motivation; everybody can't have everything they think they need-there's just not enough to go around and still have a productive economy, no matter how efficient you become. the UK and Canada ration by wait, we ration by HMO denial and ability to pay (think healthcare is available in the ER like the president claims? If you are indigent, just try to get that breast mass removed before the mets get you, or that tooth extracted before you are septic.) If we are going to ration (and it seems inevitable) we ought to have honest public acknowledgment of who gets and who doesn't and why; playing pretend like we are doing is safe politics but bad policy. Any health care economist who is being candid and off the record will tell you this is so.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-86683971226322564922007-08-01T20:48:00.000-07:002007-08-01T20:48:00.000-07:00Dr. Schwab, that's really interesting. I hope my f...Dr. Schwab, that's really interesting. I hope my future paycheck isn't too small, because my loans are getting rather intimidating. I keep waiting for that rich uncle to come to my rescue, but so far, no luck. Know any benevolent donors?Anonymoushttps://www.blogger.com/profile/04071711894125638696noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-48109181482278066022007-08-01T12:17:00.000-07:002007-08-01T12:17:00.000-07:00Bonuses based on outcomes can get a little tricky ...Bonuses based on outcomes can get a little tricky for surgeons especially. Tertiary referral centers often end up with patients that the community hospitals want no part of. The man with a pancreatic cancer invading his SMV. The woman acutely short of breath who needs a re-do CABG emergently for the third time. The case of severe pancreatitis and multiple organ failure who needs pancreatic debridement. outcomes aren't going to be so hot, no matter who does the surgery. It's simply a reflection of patient selection.Jeffrey Parks MD FACShttps://www.blogger.com/profile/15650563299849196122noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-75512208181163593562007-08-01T05:33:00.000-07:002007-08-01T05:33:00.000-07:00"Bonuses based on health on patients"Talk about hu..."Bonuses based on health on patients"<BR/>Talk about hubris.Do we really think that the health of patients in under our control.Sometimes we help peple because we know what we are doing and we do the right thing and the patient cooperates. Sometimes the patient has great genes in regard to the issue at hand and they do well anyway. People live and die and much of time survival is unrelated or barely realted to what we do.So we should be paid more if our patients have good biological systems that keep them going longer.james gaultehttps://www.blogger.com/profile/05537303135780186926noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-13134386573580813142007-07-31T19:13:00.000-07:002007-07-31T19:13:00.000-07:00anne: good question. I think for people my age, th...anne: good question. I think for people my age, there weren't a lot of worries; maybe that's why so many are now unhappy. We came in on the tail end of the times when the main worries were what you wanted to do, and where. Finding a good location wasn't a sure thing, but it wasn't a problem for anyone who'd done well. I think that part is still true; but I don't think many of us worried that we'd make a decent living. Frankly, I never really thought about money at that stage. I saved $4000 of my $8000 salary as an intern. It was more than I'd ever made. I went into the military after internship and with combat pay and flight pay I thought I was rolling in dough. I made $12K as a chief, and my guarantee when I started practice was $30K. At every stage, it was more than I'd ever made. When I started in practice, my partners asked how much surgery I thought I'd want to do to feel useful. Ten cases a week? You'll kill yourself, they said. Six cases is nice: you can make a decent living and have time for a life. By the latter part of my career, I was doing up to twenty a week, and making about what those guys were making, in comparative dollars. So I went from the time of little regulation, fee for service, to that of lots of rules, many carriers calling lots of shots, and steady decline in reimbursement. I can't say the old days were fair: I think, for example, you ought to be doing more than six cases a week. But right or wrong, a lot has changed. I think it's not just money for your generation; it's uncertainty of what it will look like 10 or 20 years from now. Me? I'm hoping not to get sick.Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-30459503189413883522007-07-31T17:42:00.000-07:002007-07-31T17:42:00.000-07:00Just out of curiosity - What was a big concern whe...Just out of curiosity - What was a big concern when you were just starting out in medicine? My generation is of course concerned about paying back loans when our paychecks get slashed in the name of HMO.Anonymoushttps://www.blogger.com/profile/04071711894125638696noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-28001880003001460892007-07-31T16:27:00.000-07:002007-07-31T16:27:00.000-07:00Great post. Re: salary; some years ago I worked in...Great post. <BR/><BR/>Re: salary; some years ago I worked in a hospital-owned clinic. We three FPs were on salary. One would always, always leave on time (or early!), leaving whatever still needed to be done to the other two, knowing we would because we didn't want to leave the patients in the lurch. I left as soon as my contract was up or I might have gotten bitter. I suspect we were a perfect microcosm of what it would be like to have all docs on salary. <BR/><BR/>Re: Medicare payments to doctors going up, TOTAL payments are going up because of spiraling demand. Reimbursement for any given service is not going up much or in some cases not at all. So docs are making less for a given amount of work.<BR/><BR/><BR/>Pick your poison--should docs get paid for doing work--I include "cognitive" work ;) or for *not* doing work, as when capitated or salaried. If I were the patient, I'd pick the former.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-84858075550939937082007-07-31T16:02:00.000-07:002007-07-31T16:02:00.000-07:00The short term? You mean the 12+ years it will ta...The short term? You mean the 12+ years it will take between any attempt at increasing the supply of physicians to account for decreases in the work done by the current ones?<BR/><BR/>Well, I certainly hope you don't break your arm in that "short" 12 years then.<BR/><BR/>There is an enormous amount of "free labor" by physicians put into the current system out of good will and professional obligation. If the government wants to crack it in an attempt to pinch pennies, it will be surprised when it turns out to cost many more pounds. The British NHS offered doctors a pay cut in exchange for giving up night call because they didn't believe those lying doctors about how much they worked for free. Turns out it was actually a massive underestimation and the doctors are enjoying their free nights as the NHS must now pay billions more because it's not being done for free anymore. Careful what you wish for...Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-48496123663755122472007-07-31T13:58:00.000-07:002007-07-31T13:58:00.000-07:00Even if all those things come to pass, I'm willing...Even if all those things come to pass, I'm willing to bet we'll also see an influx of capable, smart, committed young physicians who are utterly content to accept a salary, rather than unlimited wealth, in exchange for a controllable schedule and a 50-hour workweek. The ones who drop out because they can no longer overtime their way to a Porsche Carrera GT will be replaced (sooner or later) by 40-year-old women who seize the opportunity to both save lives AND see more of their kids. That's the "different sort of person" you'll see more of. Wait times may peak in the short term, but they'll flatten out again as the supply adjusts.Anonymousnoreply@blogger.comtag:blogger.com,1999:blog-30499448.post-76826765118516629092007-07-31T09:43:00.000-07:002007-07-31T09:43:00.000-07:00rlbates: yeah. After the latest list of rules, the...rlbates: yeah. After the latest list of rules, the most recent hassle with this carrier or that, I've often said, just give me a salary: tell what it'll be, and if I can live with it, I will, and if not, I'll find something else to do. <BR/><BR/>rob: I was hoping you'd be the one.Sid Schwabhttps://www.blogger.com/profile/14182853083503404098noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-88560769127497694282007-07-31T09:36:00.000-07:002007-07-31T09:36:00.000-07:00I agree with your assessment (see my last post on ...I agree with your assessment (see my last post on free market). The whole thing is a big mess and I think that one of the biggest things is to get the other fingers out of the pie. Too many people are leaching money out of the system for no other reason than the fact that they can. I do believe in rewarding quality and rewarding hard work (Salaried physicians do not work as hard as those motivated by profits). The problem is defining quality and really rewarding the work and not how well you play the game.<BR/><BR/>If you can fix the problem, I will campaign for your election as Emperor of the Universe.Dr. Robhttps://www.blogger.com/profile/01871792467587364512noreply@blogger.comtag:blogger.com,1999:blog-30499448.post-71915233638533257432007-07-31T09:26:00.000-07:002007-07-31T09:26:00.000-07:00It is certainly a can o'worms. I, like you, try n...It is certainly a can o'worms. I, like you, try not to let what I will get paid be a deciding factor as to which procedure (if any) a will do for a patient. I have talked many women out of breast augmentations (even when I needed the income to pay my overhead). Sometimes I would love the security of a "salary", let others worry about the rent, utilities, but I worry then that "they" would tell me I "had" to do the operation as "they" would want the payment.<BR/><BR/>Sure wish I had the answer. I work for the patient. My reward is a good outcome. But I have learned you can't be here to give service, if the overhead is not met.rlbateshttps://www.blogger.com/profile/15236331355857884458noreply@blogger.com