Breakdown of Incentive for Doctors Re: Universal Healthcare?

[K. A. Pital]

Maybe by offering everyone in society decent pay so that nobody feels particularly bad and denigrated by his occupation? Doctors are human, but so are the others. It should be a rewarding occupation, but I haven't personally felt the US doctors were "cream of the crop" who somehow were much better than European ones who operate under the horrible socialist system of universal insurance and no-profits basic insurance packages (feels so bad for the poor struggling insurance companies who then have to make their money off wealthy clients, lol). Maybe it's only the oligarch doctors whom I'd never even see anyway. I don't care about the quality of healthcare oligarchs get. I want them to get what ordinary people get. And die if that quality isn't good enough to keep them alive.

[Me2005]

1. If someone becomes a doctor "just" to get rich, then I think they are destined to not put their patients first, (unless doing so directly benefits their income). I fully admit that this can be a strawman position - realistically, I expect doctors to at least be ethical enough to realize that they must care for their patience at least a little.

I doubt that this is often the case, and if it is, the person is likely a strong type-A (as are most doctors) who needs to practice correctly in order to achieve their goal. Not treating their patients well would not lead to success, so they wouldn't do that. Even being completely amoral, if someone wants to do it *only* to become wealthy they'd either have to be a complete con (and risk getting caught for that when the thing folds) or else do the work properly. Others who want to be doctors to get rich wash out if they can't do the medical part to some standard.

4. You can also partly address this issue via some reform in the law - like maybe require doctors who have a private practice to serve X amount of hours in a regular hospital, or to otherwise retain some association thereof. You can also offer something like merit-based free medical schooling - have special pre-med entrance exams, and if the test takers do well enough, offer free medical schooling, provided they maintain their strong performance and agree to serve in a state or other municipal hospital for X number of years.

I think this (or similar) is already in place in most jurisdictions, especially those with a shortage of doctors. I know one of my friends is getting med school partially/wholly paid for by working in the state for some number of years.

[Broomstick]

2. Malpractice is a huge issue - yes, doctors should absolutely be held accountable for negligence or simply cutting corners, but frivolous lawsuits need also be strongly deterred/punished. No treatment is 100% effective, and a person may not get the result they want, even with the best doctor(s).

There would be less incentive to sue if the cost of long-term or expensive care was covered by a universal health system instead of becoming a crushing burden to the family.

4. You can also partly address this issue via some reform in the law - like maybe require doctors who have a private practice to serve X amount of hours in a regular hospital, or to otherwise retain some association thereof. You can also offer something like merit-based free medical schooling - have special pre-med entrance exams, and if the test takers do well enough, offer free medical schooling, provided they maintain their strong performance and agree to serve in a state or other municipal hospital for X number of years.

In some ways, this already exists. 30 years ago my college roommate had her medical education paid for in return for promising 7 years working in an underserved area assigned by the government. These problems already exist.

[Block]

2. Malpractice is a huge issue - yes, doctors should absolutely be held accountable for negligence or simply cutting corners, but frivolous lawsuits need also be strongly deterred/punished. No treatment is 100% effective, and a person may not get the result they want, even with the best doctor(s).

There would be less incentive to sue if the cost of long-term or expensive care was covered by a universal health system instead of becoming a crushing burden to the family.

No there wouldn't. People sue hoping to get lucky and strike it rich, not because they necessarily have an actual case.

[Napoleon the Clown]

2. Malpractice is a huge issue - yes, doctors should absolutely be held accountable for negligence or simply cutting corners, but frivolous lawsuits need also be strongly deterred/punished. No treatment is 100% effective, and a person may not get the result they want, even with the best doctor(s).

There would be less incentive to sue if the cost of long-term or expensive care was covered by a universal health system instead of becoming a crushing burden to the family.

No there wouldn't. People sue hoping to get lucky and strike it rich, not because they necessarily have an actual case.

I'd love to see a citation on that.

[Broomstick]

Please - with long-term care for a chronic disability running into the millions of dollars over a lifetime the only way to pay for it, for many, is to "strike it rich". The money has to come from somewhere so anyone with deep pockets becomes a target.

[PainRack]

To some of the OP issues: The whole system is busted as-is, and the government isn't helping by passing laws requiring more interference. If we want to go socialized, I think we'd need to treat medical professionals as essentially military forces.

Hell NO.

The British colonies has a history of this from Hong Kong,India and Singapore. That system sucks.

Hell,in Singapore, under the licensing and medical scholarship bond system, its still arguably true.
It was regimented as hell, did not prize initative and abused the worklife of its participants.

While a renewed system may not have the flaws of its ancestors, i want ironclad gurantee of that first.

Hell,my former boss tried to get us not to take MCs because of need n duty to get well and I reminded her that conjuctivitis is an INFECTIOUS disease requiring home quarantine so as not to spread and afterwards, i reminded everyone what she said was bloody illegal in both manpower and healthcare laws.

[PainRack]

Before long, these codes were attached to a fee schedule based upon the amount of time a medical professional had to devote to each patient, a concept perilously close to another Marxist relic: the labor theory of value. Named the Resource-Based Relative Value System (RBRVS), each procedure code was assigned a specific value, by a panel of experts, based supposedly upon the amount of time and labor it required. It didn’t matter if an operation was being performed by a renowned surgical expert—perhaps the inventor of the procedure—or by a doctor just out of residency doing the operation for the first time. They both got paid the same.

Hospitals’ reimbursements for their Medicare-patient treatments were based on another coding system: the Diagnosis Related Group (DRG). Each diagnostic code is assigned a specific monetary value, and the hospital is paid based on one or a combination of diagnostic codes used to describe the reason for a patient’s hospitalization. If, say, the diagnosis is pneumonia, then the hospital is given a flat amount for that diagnosis, regardless of the amount of equipment, staffing, and days used to treat a particular patient.

As a result, the hospital is incentivized to attach as many adjunct diagnostic codes as possible to try to increase the Medicare payday. It is common for hospital coders to contact the attending physicians and try to coax them into adding a few more diagnoses into the hospital record.

Just for funsies, i decided to break it down into a point by point rebuttal.

So, over here, we have his complaints on why coding procedures are bad. And hes NOT wrong. Codes dont incentivise paying more money to better doctors, they also dont account for 'true' costs of a patient. The later in particular is really problematic because a provider can get stuck with a series of poorer outcome patients and thus lose significant money. Well, or profits for other payers.

So... Why do thiz? Taiwan tells us why. Fee for services meant providers focused on volume of services and competited for doing more. Its why every country jumped on to managed care,sooner or later. Taiwan just did so much later.

http://www.theatlantic.com/health/archi ... ce/256755/

I did kinda collapse coding reimbursements and managed care together as a reply though.

The coding system was supposed to improve the accuracy of adjudicating claims submitted by doctors and hospitals to Medicare, and later to non-Medicare insurance companies. Instead, it gave doctors and hospitals an incentive to find ways of describing procedures and services with the cluster of codes that would yield the biggest payment. Sometimes this required the assistance of consulting firms. A cottage industry of fee-maximizing advisors and seminars bloomed.

I recall more than one occasion when I discovered at such a seminar that I was “undercoding” for procedures I routinely perform; a small tweak meant a bigger check for me. That fact encouraged me to keep one eye on the codes at all times, leaving less attention for my patients. Today, most doctors in private practice employ coding specialists, a relatively new occupation, to oversee their billing departments.

All true. Coding for unexplained chest pain vs angina for investigation/treatment supposeldy has a 100% difference in payment. I discarded my notes on health infomatics years ago but similar artifacts still exist i sure.

There is no incentive, through a market system with transparent prices, for either the provider or the consumer to be cost-effective.

Despite pointing to Singapore or Switzerland or India, this fact STILL hold true in every country in the world. No healthcare system , despite attempts to do so has achieved this through the free market yet.

Twenty years after the fall of the Iron Curtain, protocols and regimentation were imposed on America’s physicians through a centralized bureaucracy. Using so-called “evidence-based medicine,” algorithms and protocols were based on statistically generalized, rather than individualized, outcomes in large population groups.

While all physicians appreciate the development of general approaches to the work-up and treatment of various illnesses and disorders, we also realize that everyone is an individual—that every protocol or algorithm is based on the average, typical case. We want to be able to use our knowledge, years of experience, and sometimes even our intuition to deal with each patient as a unique person while bearing in mind what the data and research reveal.

Being pressured into following a pre-determined set of protocols inhibits clinical judgment, especially when it comes to atypical problems. Some medical educators are concerned that excessive reliance on these protocols could make students less likely to recognize and deal with complicated clinical presentations that don’t follow standard patterns. It is easy to standardize treatment protocols. But it is difficult to standardize patients.

What began as guidelines eventually grew into requirements. In order for hospitals to maintain their Medicare certification, the Centers for Medicare and Medicaid Services began to require their medical staff to follow these protocols or face financial retribution.

Once again, the medical profession cooperated. The American College of Surgeons helped develop Surgical Care Improvement Project (SCIP) protocols, directing surgeons as to what antibiotics they may use and the day-to-day post-operative decisions they must make. If a surgeon deviates from the guidelines, he is usually required to document in the medical record an acceptable justification for that decision.

These requirements have consequences. On more than one occasion I have seen patients develop dramatic postoperative bruising and bleeding because of protocol-mandated therapies aimed at preventing the development of blood clots in the legs after surgery. Had these therapies been left up to the clinical judgment of the surgeon, many of these patients might not have had the complication.

Operating room and endoscopy suites now must follow protocols developed by the global World Health Organization—an even more remote agency. There are protocols for cardiac catheterization, stenting, and respirator management, just to name a few.

Ok...before this? Wrong ideologically. After this? Bad doctoring, period.

1. Algorithims and protocols has been in medicine ever since it became scientific. I sure CPR and ACLS algorithims isnt bad medicine.

2. The most frightening words in healthcare should be trust me, based on my experience... No, your experience means jackshit against the data. The surgeons who bemoaned that total masectomies must surely be needed to treat breast cancer was replied with one of the wittiest sentences in modern history" No, I'm not saying that. The data says so." Case in point: thromblytics,stockings and etc were put in place precisely because way too many patients were dying from DVT. Saying that thromblytics had the problems of causing post op bleeding ignores the data that way more people benefit than was harmed.
Can we do better?Sure. But individual experience and intuition about which way to proceed is dangerous.

3. The standardised checklists and procedures was because way too many variances was going on and a new standard was desirable,one that preferably would allow others to base a MINIMIUM standard of care to reach to. Now,many countries like South Africa has problem reaching these standards but..... America?

It gets even more funny because the surgical safety checklist was engineered by American surgeons, its WHO proponent included Atul Gawande and is entirely critical of how medicine is the only field that preaches its master guildsman can do whatever it likes based on their perception.

Its called standards. A good doctor knows when you need to do more and adapt, but that why this isnt called protocol based medicine or cookbook medicine. Its evidence based medicine.

A large Veterans Administration study released in March 2011 showed that SCIP protocols led to no improvement in surgical-site infection rate. If past is prologue, we should not expect the SCIP protocols to be repealed, just “improved”—or expanded, adding to the already existing glut.

Each individual recommendation, from pre surgical abx and hair removal was evidence based to reduce post op infection. Implementation of SCIP as a whole however had mixed results. OMG, medicine is hard and QI projects require good management and the like to achieve results.

Say, werent you talking about the human element and how good doctors are required?

One of my colleagues, a noted pulmonologist with over 30 years’ experience, fears that teaching young physicians to follow guidelines and practice protocols discourages creative medical thinking and may lead to a decrease in diagnostic and therapeutic excellence. He laments that “ ‘evidence-based’ means you are not interested in listening to anyone.” Another colleague, a North Phoenix orthopedist of many years, decries the “cookie-cutter” approach mandated by protocols.

Protocols change every 3 years and varied in the field based on resources and etc. They heavily vetted, experimented upon when the money is present. Every fucking year i went for CPR recert, theres a minor change. Fuck . I think this year has to be a miracle because LSCN and BCLS didnt have a change. God, i worked for 6 years and I went through 3 variations of BCLS and 2 for LSCN.

Every YEAR, the doctors shift a new approach because of SCIENCE! Subcutaneous velcade? Oops, a nurse in Europe gave it s/c by mistake, hey... It works.... OMG, science shows that it reduced neurological side effects when we give it by S/C instead. Change!

And nurse/doctor gave it by IT in Europe, which caused death and was the last straw, prompting major revisions on how to give the right drug through the right route n safety.

There has never been a peer-reviewed study clearly demonstrating that requiring all doctors and hospitals to switch to electronic records will decrease error and increase efficiency, but that didn’t stop Washington policymakers from repeating that claim over and over again in advance of the stimulus.

Not then, and we now know its more complicated than that but you gotta be fucking kidding me when you can now see what ANE did for a person online and view said xrays immediately. WTF?

Its a fucking godsend. I can see immediately what was done in another hospital, verify it immediately with patient and get shit done.

And it removes the annoying habit of stressed nurses missing out important information, oh, my colleagues didnt tell me that he had a CT brain scheduled' as I swung the monitor to show said appointment to her. Honestly not her fault. But anything that helps people to stop dropping the ball is a godsend.

You an idiot if you think learning a new system means the advantages arent worth it.

The persistence of price controls has coincided with a steady ratcheting down of fees for doctors. As a result, private insurance payments, which are typically pegged to Medicare payment schedules, have been ratcheting down as well. Meanwhile, Medicare’s regulatory burdens on physician practices continue to increase, adding on compliance costs. Medicare continues to demand that specific coded services be redefined and subdivided into ever-increasing levels of complexity. Harsh penalties are imposed on providers who accidentally use the wrong level code to bill for a service. Sometimes—as in the case of John Natale of Arlington, Illinois, who began a 10-month sentence in November because he miscoded bills on five patients upon whom he repaired complicated abdominal aortic aneurysms—the penalty can even include prison.

For many physicians in private practice, the EMR requirement is the final straw. Doctors are increasingly selling their practices to hospitals, thus becoming hospital employees. This allows them to offload the high costs of regulatory compliance and converting to EMR.

As doctors become shift workers, they work less intensely and watch the clock much more than they did when they were in private practice. Additionally, the doctor-patient relationship is adversely affected as doctors come to increasingly view their customers as the hospitals’ patients rather than their own.

In 2011, The New England Journal of Medicine reported that fully 50 percent of the nation’s doctors had become employees—either of hospitals, corporations, insurance companies, or the government. Just six years earlier, in 2005, more than two-thirds of doctors were in private practice. As economic pressures on the sustainability of private clinical practice continue to mount, we can expect this trend to continue.

Healthcare=more complicated/=government fault.

The rest is...nostalgia for good old days. Yes, managed care has its cons. But managed care pioneered Chronic Disease Managemeny Program, which empowered patients to take control of their health to properly control disease such as diabetes and hypertension by adhering to guidelines. THAT the pro.

Because the 'providers' ,having seen how fee for service has failed to provide creative answers to corrall price costs and outcomes, are trying managed care. Which are incentivised to do this.

So. If you honestly believe in free markets...

Each of these models has its pros and cons. In a true market-based system, where competition rewards positive results, the consumer would be free to choose among the various competing compensation arrangements.

They DID. The payers, the insurance companies and medicare are trying this.

The patients, the ones buying the insurance policies can choose between those who follow this and those who dont.


Ultimately,when hes correct, it has nothing to do with UHC and etc, because healthcare is changing and becoming more complex,causing a cultural change.


Also, P.S the same doctors that see private patients also see NHS patients. So... What causes a drop in performance then?