Doctoring Health Care Health Care Reform

People are not units — US healthcare policy obstructs good doctoring

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.


6 replies on “People are not units — US healthcare policy obstructs good doctoring”

There are physician employment models out there, already taking good care of people, not using RVUs AND not losing their shirts. I’m employed because I couldn’t afford to stay in private practice. But I can’t afford, emotionally, to churn out patients. How many primary care doctors with years left in them if they practiced in a rational care model, will we have to lose before this changes?

Thank you for the shout out. I appreciate it. But I wonder what you think would be an improvement. I don’t think that we can remove corporate greed from the model even if we go to a model like Health City in the Cayman Islands. Someone is going to say, we can charge more if we get a CT or a MRI. It is still up to me to ask what is this test or treatment going to accomplish and how is that going to change how we are going to act? I even have to ask if there is another way to accomplish the same goal. But I usually don’t get straight answers or full disclosure. Generally my doctors give me the information that I need to make the decision that they want me to make. Until we get back to the formula where I pay you directly, you will never be working for me. And I can’t afford that. The cost of my cancer treatment alone was more than $250,000 alone. My defibrillator was over $60,000. With those figures alone we are already approaching 1/3 of what I can expect to make in my lifetime. I either crowd source with insurance, or I rely on a socialistic formula. Do you have a better plan on what needs to happen?


Why don’t you ever talk about the giant elephant in the room – Obama Care? My understanding is that Obama Care is only going to make things worse as more and more doctors are forced to go work at the “giant hospitals.” Because of Obama Care many will not be able to stay in private practice.

If we want to fix this mess we need to go to a free market system and we need to model the auto insurance industry. We need patients to pay for routine checkups and “simple” procedures. When your car needs an oil change does your auto insurance pay for it? Of course not! When you have a repair that needs to be made that costs a couple hundred dollars, does your auto insurance pay for it? No! You only use your auto insurance for major repairs.

What’s more, I can buy my auto insurance from any one, from any state (so long as they are licensed to provide insurance in my state) – and if I have to file a claim for a major repair, I can go to pretty much anyone I want to for the repair. What’s the result? Super affordable auto insurance and routine oil changes and repairs that are relatively cheap.

My hope is that in my lifetime either Obama Care is repealed or it crashes the whole healthcare system so we can start over and build it back up like it used to be. Remember when doctors did house calls, or when little Tommy had a sore throat you actually just paid for the office visit and it didn’t cost that much?

It’s sad that I have more options and “better care” when it comes to my car than my own life! We used to have health care like the auto insurance industry. I don’t know when or why it changed but it’s very frustrating.


We do not do well with strokes. tPA has only a 12% efficacy and is delivered to maybe 5-10%. Only 10% of survivors get to almost full recovery. Absolutely nothing is being done to stop the neuronal cascade of death in the first week.

Dr. John, I believe that we agree that value based care aligns incentives, and rewards doctors for objectively taking good care of patients, while keeping costs in order, i.e. minimizing tests and procedures. The problem is that the data collection and reporting of such care requires sophisticated IT and operational folks who manage and monitor this process. Small practices can operate in this manner but generally do not, as they tend not to invest in systems and staff, as the short term financial impact is not well absorbed. At Kareo we are trying to bend this curve so that a small practice can operate as a sophisticated enterprise. This can be done with a minimal investment in technology and staff, but does require an investment, and will produce an ROI based on improved contracting and value based incentive payments. Paying for value vs productivity should improve the overall healthcare picture, and with financial, technical and operational assistance the small practice can thrive and in fact prosper IMO.

My husband was first coerced into receiving a needless (and incompetently implanted) pacemaker at one of those giant hospitals – one at which two electros literally yelled in his face and called him stupid for not further submitting to an ICD that was specifically not recommended by guidelines. Much later, I learned that the CEO of the hospital in question was a fan of what he himself termed “forced productivity.” Translation for cardiology: Cram a lot of devices into people who don’t need them, or get called on the carpet for not generating enough profit.

Even years later, the rage I feel towards those doctors is so great that I have trouble feeling empathy for them. And yet, perhaps their lives were no bed of roses. A couple were highly remunerated true believers or Mark Mideis, but what about the junior staff? Were they like line workers in a corporate slaughterhouse, unable to consider the interests of the “product” because they were too busy scrambling to keep management from running them through the grinder too? Perhaps they have become overworked, bitter, angry doctors who rant about patients online, while we, if we can refrain from fearing death, don’t have to enter their system again. Perhaps I should pity them instead of hating them.

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