why do we continue to punich doctors over and over and over and over again? if we want to do pay for performance then apply it broadly! can we have CEOs that run companies to the ground work on P4P? maybe instead of the 100million golden parachute they can have their pay deducted when the factory workers don't show up to work, or drink do drugs while working thereby reducing the productivity

how about lawyers go on P4P? we will have lawyers reduce thier fees when their clients don't take thier advice and drink and drive getting another DUI.

when i keep hearing about all the crap thery want is to lead and be role models for i just think back to the movie "old school" when frank the tank "leads" the streak but nobody follows...physicians are the frank the tanks of the world because we all think we should lead and be professional models while the rest of the professions just laugh all the way to the bank

i am spending my time filling my head with knowledge, working 70-90hrs a week so that i can practice medicine...by practicing medicine i am putting out a product (medical advice) why should i be paid less for it?

and you think this P4P is so great? i will bet my left epidymidis that this will backfire so quick you will wonder what the hell happened..i'll spell it out for you: P4P basically pays more for good results, good results come from practicing evidence based medicine but mostly good results come from healthy compliant patients....the only thing that P4P is going to accomplish is that more and more docs are going to tailor their practices to have good numbers by only keeping healthy compliant patients..the gomers and gomeres will be turfed to your local ER where an already crumbling infrastructire will be further strained taking care of the wake left over from your wonderful P4P system.

is it coming yes but many docs are not taking it and are already starting to refuse insurance. so the US does not need socialized medicine to have 6 month waiting times we just need to further burocratize and penalize doctors to the point where it will no longer be worth it to work

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AUC M.D. Class of 06'
OBGYN PGY-1.5

I hate Internal Medicine more than fascia

medical diagnosis is not easy otehrwise it wouldn't take years to try and learn it..if it was easy and straight forward then any mcdonalds university grad could play house m.d.

when you look at a patient you have a list of 3-5 most common things based on your experience and training and those 3-5 things will probably not be in the same order on anyones differential and you have to work through it

as far as diagnostic tests..the amount of diagnostic tests is partly a function of trying to acheive the diagnostic perfection you require by proving a definitive diagnosis before treatment..trouble is there is no one test for anything and everything which takes you back to your differentials and working through them...its a conundrum i know.

the other equation to this diagnostic test boom other than every patient demanding the newest and most expensive test of course is the CYA factor that you can thank our legal profession for making the practice of medicine less about physical diagnosis of pertinent positives and more of a "rule out" mentality in that in order to diagnose F you fisr have to rule out A,B,C, D, and E while also considering ruling out G through Z just in case the patient may have traveled to sub saharan africa and became infected with Kuru while on a cannibalistic binge

__________________
AUC M.D. Class of 06'
OBGYN PGY-1.5

I hate Internal Medicine more than fascia

I don't think the proposals for caps apply to individual doctors but are applied at an aggregate level (e.g. hospital). On the other hand, there are lots of other systems that are being put in place for pay for performance. These tend to reward doctors for practicing evidence-based medicine and using resources wisely. While the current systems are not perfect, I think they will get better over time. I don't think these are a bad thing. As Wennberg's research shows, there is huge variation in practice. Thus, a large percentage of doctors follow suboptimal practice. For example, in the book, Epidemic of Care, the authors (former CEO of an HMO) found that only 50% of doctors in their care network managed diabetes appropriately. Similar results have been found for management of patients with heart conditions (e.g. prescribing beta blockers). As the saying goes, "What gets measured gets managed, what get's rewarded gets done". Thus, measurements and rewards will provide the incentives to improve performance.

Most of the doctor incentive systems are process based vs. outcome based. Thus, doctors are rewarded for following evidence-based guidelines but not for turfing sick patients.

I think one can argue about the methods used to measure and reward performance; however, I think the overall strategy makes sense. Why should medicine be any different from anything else in this regard?

A few things.
Medicine is probably the only profession I can think of where people expect you to do you job for free. I can't tell you the number of messages I get from a patient I haven't seen in 2 years with content like: "Has sinus infection, wants antibiotics". Hmmmm, a simple request....why not just call in some amoxicillin? Make life easier on the patient. Let's say that guy is a mechanic. Does he tell people how to change their alternator belt for nothing? Nope. Suggest it to him, he'll tell you you're an idiot. Even better are the messages like "has severe abdominal pain, can't come in for an appointment, wants to discuss with you." Hmmm, since my crystal ball is broken, you need to either come in to I can press on your belly, or you need to go to the ER so someone there can press on your belly. These people get mad when you don't treat them over the phone. My liability in treating someone over the phone is huge. "No, your honor, I didn't examine them, but they TOLD me they weren't having rebound on the phone, so it sure didn't sound like a ruptured appendix....and I did send flowers to the funeral"

Pay for performance.
This is going to do more to hurt patients than Medicare Part D. As primary care docs the most glaring example is treatment of diabetes. Lets say to get a bonus, we have to make sure that 80% of our diabetics have a Hemoglobin A1C below 7%, a blood pressure below 130/80, and a LDL of less than 100. I work in a suburban/urban area. I have quite a few patients that are not compliant no matter how much time I spend with them. (I have 2 ladies who I call once a week to adjust their insulin, but they never get it right). So I look over my roster and note that only 72% of my patients are at goal. I'm gonna miss out on many thousands of dollars I could use to pay my >$200,000 in debt I accrued so I could be the wealthy doctor I am . Can you predict what may happen? If you guessed that a bunch of people are going to get a letter telling them they need to find a new doctor....you guessed correctly. Now I have over 80% compliance. Now I get my extra money. (not saying I will do this, but I'm sure you will agree it will happen, a lot.)

No charge for follow-up visits:
Someone mentioned the surgery office they worked in didn't charge for follow-ups. That is correct. The follow-up visits are built into the fee schedule for the procedure, so the surgeon has already been paid for it.

Multiple Follow-up visits for the same problem.
I have people I have been seeing for years for the same problem. They keep coming with it, and I can't figure out what the problem is. I have sent them to specialists (including some at Johns Hopkins, supposedly one of the greatest hospitals on the planet) and they can't figure out what it is. Should I still see them when they come in with the same complaint? Should I charge them? I saw a woman in the office last week who for 2 years has had unexplained weight loss and abdominal discomfort. She has had every test you can imagine. CTs, Ultrasounds, MRIs, tumor markers, a laparoscopy, colono, EGD, the endoscopy with the little camera you swallow...all normal. Labs are always stone cold normal. Last week was different. She had small palpable masses in her abdomen on exam. I think I may have found her problem. It isn't good, most likely.

I get paid mostly for thinking about your problem or researching your problem. Just because I didn't come up with an answer, does that mean I shouldn't get paid for the time I invested? Lawyers can charge you for time they spend thinking about your issues.

That being said, there are a lot of docs who bring people back pointlessly. I call people with their lab/imaging results, I don't bring them back in....

__________________
AUC Class of '99
Bored certified
I may be a jerk, but I'm a Jedi jerk like my father.

Some say I look like Buzz Lightyear....
(They're right)

DISCLAIMER: I have no financial stake in ValueMD, or any medical school.

I like that analogy. My doctor never charges for a follow-up if you are coming in for test results.

Last year I had a problem with my home A/C, it turned out to be the control motherbord. The A/C guy told me that was not included in my warranty. He quoted me 700 buck just for the part and installing it for , guess, what, 1200. yes 1200 not pesos but USD and he did not bulge, he said he has to charge for his service just like a lawyer or a doctor would. I got 3 otjer quotes, the cheapest...600.00. I got the part from an online distributor for 160.00 USD with instructions included, but since written instructions can/t beat a picture I took pictures of the old installation and did it myself. The a/c is runnung great.

Bottom line of this story...Teratos is right, if you ask your mechanic how to change the alternator so you can save some $$$ he will laugh on your face and call you an idiot. A lawyer...try between 200.00 and 300 per hour, and they will bill you even for using the copying machine.The same goes for any professional service fee, doctors included, we all have to make a living and pay bill, unfortunately, chickens and oranges won't pay such bills or 4.00 bucks a gallon of gas.

My thoughts only.

Cheers

Max

__________________
...."Beyond jealosy and betrayal; beyond hate and desire; beyond pain and death; lies the ultimate revelation; the final choice; the end; because the fate of destruction is also the joy of rebirth" Neon Genesis Evangelion

Well that is just the way doctors deal with rising malpractice, falling insurance payments, all the other overhead that is increasing. Despite that doctor incomes in a country with socialized medicine called the United Kingdom is actually higher for PCPs at least, the average UK GP makes 200k a year, considering that the Greenback is going to tank further, probably more like 215K a year by the end of this year. If you hate it that bad move to a country with socialized medicine, of course you will pay a lot more taxes too.

Don't get me wrong, I love what i do. What I get annoyed with is that people expect me to treat them over the phone. It seems simple enough, right? They call, tell me they have a sinus infection...they have already made the diagnosis, so my job is easy...why can't I just call in the antibiotics? It has nothing to do with rising malpractice, or decreasing reimbursements. It has to do with how I get paid. I get paid for seeing people. Do they do the "easy" parts of the their jobs for free? I doubt it. I could care less what a doc who is in a country where there is socialized medicine makes or does. That isn't me, and they aren't providing the quality of care we do in the US. There are far too many examples of that.

Gimme a call when you are in practice. Lemme know what you think. G

__________________
AUC Class of '99
Bored certified
I may be a jerk, but I'm a Jedi jerk like my father.

Some say I look like Buzz Lightyear....
(They're right)

DISCLAIMER: I have no financial stake in ValueMD, or any medical school.

Money isn't everything and it is not the only thing either. All the money in the world could not bring back my beloved Marie. She was the woman I once planned to marry, and she was killed in a car wreck a year before I started medical school. All the money in the world won't bring her back to Earth.