Tuesday, October 06, 2009

More Pay For Less Work!

Who wouldn't want that? That's an admittedly uncharitable interpretation of an argument frequently raised at MedRants in relation to primary care providers. Primary care providers are compensated poorly in comparison to many specialists and, although compensated quite royally in comparison to the average working adult, that's the measure a lot of medical students use when choosing their eventual field of practice. Also, the current insurance compensation scheme pays per service provided, so to maximize income healthcare providers need to cram more patient care into less time. So we're presented with two arguments,
  1. It will improve patient care to allow doctors to spend more time with their patients, and thus compensation schemes should be adjusted to compensate doctors for their time as opposed to by service or procedure provided; and

  2. To encourage more doctors to enter the field of primary care, where more practitioners are desperately needed, we should increase their compensation to a level that approaches or matches the compensation received by specialists.

On their surface, both of these proposals seem reasonable. The problem is, they would both massively increase the cost of healthcare and would not necessarily provide the anticipated return in the quality of patient care.

The notion of paying per service or procedure appears to come from the idea that a particular action by the doctor could be performed in a set number of minutes, and compensation should be tied to performance and not to time actually spent with a patient. The efficient doctor sees more patients and earns more money. A doctor who is less efficient earns less money. I do have sympathy for a doctor who attempts to improve patient care by spending more time with each patient, sometimes a lot more time, and that doing so often will benefit patients.

The problem is, no insurer or employer will ever completely abandon efficiency measures. Doctors getting paid a salary will be expected to complete the work assigned to them. Those compensating doctors for the services they provide will never approve of a system where a doctor is paid to spend an hour talking to a patient before performing the procedure or service that brought the patient to the doctor. Many patients would like the opportunity to spend more time with their doctors, and concierge practices usually do provide that possibility, but few can afford that luxury.

I will grant that a salaried doctor can negotiate with his employer to have more time to spend with patients, and as the cost of the doctor is fixed the employer will be able to make budget and staffing decisions with that negotiated workload in mind. But for doctors who aren't traditional employees, as soon as you bring efficiency into the equation we're back in the same situation. Whatever the compensation, if it's possible to earn more by cramming more patients into the day, many doctors will do exactly that. And the doctors who choose not to do so will once again complain that they're being undercompensated in relation to their peers because of the time they're spending with their patients. Remember, the issue isn't that doctors can't spend more time with patients even under the current compensation scheme - the issue is that they want to be able to do so while earning the same or more money.

Another approach might be to assign an amount of time to each medical service, such that doctors would be compensated by the service, would have ample time to spend with their patients for each procedure, while capping the number of minutes they could claim for any particular day's work. I don't think it's much of a solution, as even assuming the limits could be policed and enforced, some doctors would invest that time in patient care while others would see it as a mechanism for getting out of the office by noon each day - see patients as quickly as possible, then call it a day. Meanwhile doctors would be able to see fewer patients, exaggerating the already existing shortage of primary care providers. As you can see, I'm having a hard time envisioning a compensation scheme along this line that would actually work.

The proposal to pay primary care physicians more isn't of itself unreasonable, as it does appear that the best way to attract more physicians into primary care is to reduce the differential (or anticipated differential) between primary care earnings and specialist earnings. Another way to tackle the issue might be to reduce compensation for specialist care and use that money to boost primary care compensation, but that would be a complex undertaking and I expect that it would be vehemently resisted by doctors.

But aren't we really just presenting another twist on the concept of "relative poverty" - that poverty shouldn't be measured by what you do or don't have, but by comparing your assets and income to those of your peers? If we were to simply offer an across-the-board increase in the amount provided as compensation for primary care services, how long would it be before specialists were demanding a similar raise? (I don't think the ink would even be dry on the new compensation schedule before those demands came in). And if granted, we're back where we began - with a continued, significant differential between primary and specialist care, with a similar distortion of how medical students choose their areas of practice - but at a significantly higher cost to patients.

Although Dr. Centor links with approval to the argument that medicine should not be about money, and granting that his primary concern is to improve the quality of medical practice and not doctor compensation, the only incentives he points to and the only reforms he proposes revolve around money. There are other approaches to the problems that could be discussed. For example, even though I'm sure Dr. Centor could provide a good argument why doctors would do the job better, patients with more complex health needs could be assigned a case manager, LPN, or physician's assistant to monitor their care and help them better understand their options at a significantly lower cost than assigning those same tasks to a doctor.

I appreciate Dr. Centor's argument that "We must eschew any system that discourages us from spending time with patients", but I unfortunately have yet to hear any explanation of how that can be done except in the context of concierge medicine, or possibly by somehow bringing a Mayo-style (salaried) practice to the rest of the country.

1 comment:

  1. I concur with your comments regarding breaking the MD's monopoly on the provision of health care services and the empowerment of RNs and PAs (in fact, I seem to recall reading a very good paper on that topic with your name on it a number of years ago . . .)

    I would add that the other way to help bring market forces to bear on the problem would be to provide incentives (either through scholarships to traditional medical schools or by expanding the number of government medical schools)to increase the pool of primary care physicians. Sort of like what they do now for under serviced geographical areas, only a larger program aimed at primary care physicians.