Tuesday, July 06, 2010

How Do Cardiologists Want to Get Paid?

According to the American College of Cardiology, here's what you get when you ask nearly 400 of 'em:
Nearly two-thirds (63%) of cardiologists in private practices are currently compensated on a fee-for-service basis (FFS) exclusively; and, similarly, nearly two-thirds (65%) of these private practice cardiologists indicate that their ideal compensation is fee-for-service. Some of this response seems to be related to fear that doctors are due to be shafted regardless of what form of reimbursement is used. Therefore stick with the devil you know -- even if it is constantly declining.

Conversely, more than three-fourths (78%) of the cardiologists who are not in private practice currently receive a salary as their primary source of income. However, interesting to note is that only 57% of these cardiologists state that a salary is their ideal form of compensation. Fee-for-service (19%) and a mixed compensation system (22%) actually gain strength among them for ideal compensation. This makes sense. Salaried cardiologists deserve incentives for productivity (everybody doesn’t work as hard) and quality (everybody doesn’t strive as effectively for better outcomes). Incentives have to be based on relevant data comparisons—not conjecture.
In my view, fee-for-service is effectively (and appropriately) on life-support and fading fast. Oh sure, "concierge" fees can make up a difference between medicare payments and drops in fees for a while in affluent areas, but these fees do nothing to address the very real needs for doctors in less affluent or rural health care delivery areas. On first blush, the market is moving to a health care system salary-based structure, but straight salaries do little to promote team collaboration nor reward exceptional personal effort. If productivity incentives are added to straight salary structures, there is a risk of promoting of even more testing to benefit the hospital (and hence employee-doctor's) bottom line at the expense of the patient or their insurer.

Of course the whole damn physician payment mess is complicated by a billing coding scheme that is so ridiculous, arbitrary, and insane that no matter which method you pick, it can be gamed to everyone's benefit except the patient. Get rid of THAT system and we might be able to talk about REAL physician payment reform.


Pay ALL doctors, be they specialists or not, a fair, market-based hourly wage for work performed. That's ALL work: from the most mundane e-mail response or medication refill to the most time-consuming history-taking or complex neurosurgical procedure. Pay them time-and-a-quarter or time-and-a-half for after hours duty.

Since most of our legislature are lawyers, even they should understand this concept, right?

Imagine: no diagnosis codes, no procedure codes, no coding specialists, no 500,000 permutations and combinations of procedure codes that must match pre-determined and frequently varying diagnosis codes. If hospitals and government want to screw with that system - go for it - but keep the physician workforce separate from these coding shenanigans. Pay us what our time and intellectual capabilities are worth. Period.

And what might these hourly wages be?

That would have to be worked out based on training, years of practice, malpractice risk, board-certification, etc. But compared to the mess we have now, I'm betting this system would be a whole hell-of-a-lot more understandable and transparent than the monkey business we're doing now.



Mike said...

I agree 100%.

Anonymous said...

but how would the ama make any money if it couldn't sell its cpt system? how would the emr vendors make a case for upgrades to the billing components of their software?

#1 Dinosaur said...

Hear, hear!!

Anonymous said...

Most of your legislators never practiced a day of law in their life, at least the kind you bill an individual client for.

You found the nail, but you only glanced at it. The thing is not that all doctors need to be paid hourly a set wage. They need to set THEIR OWN VALUE, and let the market decide from there. Don't wait on the government to decide, because frankly it shouldn't be uniform. A more skilled physician should be able to charge more.

Nor should you be limited to hourly. It may be more profitable for the physician, and more effective for the consumer, to pay a set fee for a procedure. Let them have that option if you want.

Don't be constrained in your thinking.

Anonymous said...

You could do us all a service by trying to approach the problem from a patient's point of view. What a patient wants is:

1. Competent care. How can he rate doctors?

2. Clear pricing. Have you ever called around to price a simple colonoscopy?

3. Fair treatment. Every patient wants to be treated on a MFN (most-favored-nation) basis, meaning the physician should not practice price discrimination.

4. Not being charged for services not rendered. There need to be discounts for cash payment, relief from insurance/medicare reporting, and other expenses attributable to services the patient does not use. In the case of a cash-paying non-insured customer, he should be entitled to a discount from even the Medicare allowances, of course.

How can you facilitate the patient's search for competent, cheap and fair care without relying on codes?

Anonymous said...

As a cash-paying non-insured patient, I prefer to deal only with physicians who shun all third-party payment schemes, including insurance, Medicare and Medicaid.

If it's in the physician's best interest to get out from under the coding and delayed-payment scheme as well, what's the problem?

I'm waiting for your list of physicians who do not accept 3rd-party payment! I have read about one or two in the country.

Anonymous said...

On determination of salaried physician pay, you say, "That would have to be worked out based on training, years of practice, malpractice risk, board-certification, etc. But compared to the mess we have now, I'm betting this system would be a whole hell-of-a-lot more understandable and transparent than the monkey business we're doing now."

There is a better way: it's called supply-and-demand pricing and it has NOTHING to do with any of those factors you cite. If this country had been run on the basis you recommend, we'd have had no Henry Ford, Thomas Edison, Wright Brothers, Bill Gates, Michael Dell, Walmart, Google, Facebook and so on.

What we need in medicine is some of those contributorsand fewer board-certified teachers, lawyers and physicians. Hell, I design nuclear weapons, missiles, bombers and fighters and have never been "certified." Certification is for protecting deadwood.

Arie Friedman, M.D. said...

Bravo, Wes!

Anonymous said...

you are so right on but AMA will never let that happen! Their whole existence depends on coding and ICD 10 is coming up fast. AMA likes to keep thigs complicated that makes no sense in real life, why should doctors care about billing, they should care about patients and their well being which gets complicated with all the hoops they make them jump through

Jay said...

Interesting comments.

Anonymous #2 suggests that physicians should set their own value and then let the market sort it out. That way the "best" doctors could charge the most.

That would be fine if it were possible for the patient (i.e. the consumer) to assess value accurately. I would argue that this would be very difficult.

Because of the complexity of medicine and the privacy barriers present, patients have no easy way to tell if the care they are getting is a good "value." I don't think traditional market forces can apply here. The best paid doctors would probably be those who market themselves the best, rather than those who are most competent. There is no way for one the "comparison shop" when you cannot "examine the goods."

Let's also not forget that the stake are REALLY HIGH when your dealing with health care. One wrong decision based on cost could have lifelong adverse ramifications that are irreversible.


Anonymous said...


Your same argument could be made about cars and safety.

Anonymous said...

Also Jay has not heard about Consumers' Union, UL, Newsweek, PC World and the numerous other organizations that rate products ranging from cars to safety devices, Law Schools and even the teaching ability of the profs at your university.

If I can't rate a physician or hospital myself, I can sure pay for a rating by someone who has built a track record. The fact that it is a "life or death" decision makes the current system seem the most stupid possible. Maybe we should choose doctors the way we choose our jurors.