There is a lot of talk about rewarding value in US healthcare. Don’t believe any of it. It’s not happening. Not even close. This is a post about the real world–where I practice medicine.
In a comment on yesterday’s post, Lisa wondered how I connected the current model of employing doctors and paying them on productivity to the three trends I wrote about on Medscape Cardiology–fear-mongering, lack of communication, and treating diseases not people.
I started to explain in the comments section but then realized the topic was big enough to warrant a new post.
To be blunt again: the current model in which behemoth health corporations employ doctors and pay them based on productivity rather than skilled doctoring is outstandingly bad. This egregious policy makes it harder to take care of people. And that is awful.
First, the upside of the behemoth medical center: Lisa likes that all her specialists can share data and be in close collaboration. That’s a good point. Another upside is that based on probability alone a patient is likely to find skilled caregiver(s) in a place that large. But good care is not guaranteed.
A few years ago I sent an AF patient to a famous referral center. He ended up seeing an eminent physician who basically told him to buck up and put up with his disease. The doctor who said that has one of the biggest names in cardiology, a man who chairs sessions at meetings I cover. It was a horrible consult.
I offer this anecdote not to knock down referral centers, but to show that big medical centers don’t deliver care, people do. It is possible, therefore, that the most skilled doctor works in a less famous hospital across town from the famous center. Maybe. You just don’t know.
Now to the ugliness of employing doctors and paying them for the number of cones they put on the truck. (Sorry for the euphemism, but it works.) The reason why I chose to introduce the Medscape article with the employed-physician model is that I think it is one of the root causes of bad doctoring.
Think about it. Good care is usually slow care. Employing doctors and paying them to produce (and enter data in computers) impairs shared decision-making. It devalues spending the time it takes to teach people to help themselves. Minimally disruptive care, eg, good doctoring, looks bad on a productivity spreadsheet.
At a recent meeting with hospital executives, a gathering called to discuss our next contract, I raised the issue of the changing model of compensation. I naively said doctors would soon be paid by how effectively they took care of people, and not by how many tests or procedures they ordered. “Yes, John, you are right; that is coming, but not in your career. In the foreseeable future, it is all about the rVU–relative value unit,” the executive said.
So maybe now you can see the connection. The first trend I wrote about in the Medscape article dealt with my increasing role in removing fear. US hospitals (employers) and doctors (employees) are induced to produce fear. Fear in healthcare means more testing, more units. You need that test “to be sure things are okay.”
The second trend I wrote about was the lack of communication of basic health facts. Again, neither hospitals nor doctors financially benefit when patients help themselves or when patients understand basic statistics. It’s the opposite. Spending time with patients to discuss absolute benefits/risks of treatment, or how lifestyle changes are often the best medicine, does not pay as well as stress tests, ultrasounds and CT scans do.
No one would argue the US healthcare system fails to care for patients who are very ill. We do well with heart attacks, strokes, and cancer. Ebola, too. There is no way Ebola death rates would be that high in the US. Our intensive care would save the majority of infected patients.
The problem is that most patients entering the US healthcare system are not having a heart attack or infected with Ebola. For too many Americans, healthcare here delivers neither health nor care.
The more I write about how bad our productivity-based health policy is, the more I think we should abandon it. If we have to have big medical centers, put doctors on salary. Make it a good salary so young people will want to be doctors. But the nonsense of paying caregivers to do procedures, order tests, induce fear and manage diseases rather than people has to stop.