I found this link on the Medical Post. The jist of the article is the "surprising:" finding that pay for performance does not enhance medical care.
The one constant I have found during my medical career is that without exception people want to make the most money they can by doing the least work they can. This can also be extrapolated to organizations if you want. There are of course workaholics that we all know but they benefit in other ways. Quite frequently because of the volume of work they do, they are well compensated (including taking advantage of after hours incentives by doing their elective cases after hours) and by working hard they avoid stressful family situations( not to mention opening up a perfect cover for the extramarital affairs so many of them seem to be involved in). Quite frequently physicians and other people perceived as workaholics, don't work all that hard, rather they expect other people to work hard for them.
It should be no surprise that if you offer carrots to intelligent psychopathic individuals (which describes 90%) of doctors, that they are going to find a way to get those carrots in the most efficient way possible. About two years ago for example our medical society negotiated a complex care fee for family doctors. The idea was that for every patient who met certain criteria, they would be able to once a year bill about $200 for the care of the patient. An incentive for doctors who kept patients with chronic problems keeping in mind the many aspects of the care of these patients don't fit fee for service codes. The economists who reviewed the fee estimated the average family doctor would bill 7 of these a year. Within a month or some many family docs were billing 7 of these a day.... every day. There are ways of auditing this which they probably didn't anticipate and of course auditing is never a pleasant task. I somehow don't think the poor patients with the chronic conditions are getting any better care from their doctor despite him getting the extra $200 a year. (Some of them I suspect probably never realized they had a chronic problem).
This of course reminds me of a story somebody told me. A long time ago our province brought in a fee for "lifestyle" counselling which paid about twice what an office visit paid. Very quickly they noticed one doctor was billing 40 of these a day. Somebody called him and asked him how he was able to do this. He told them that at the end of the visit he would say, "try to stop smoking". This fee no longer exists.
The fee for service system is of course a mini pay for performance scheme where the more patients you get through, the more you get paid. This doesn't of course say anything about quality of care but at the very least patients do get seen. In fact often the best care is no care at all, and there doesn't seem to be a way of paying for that.
About 7 years ago our neurosurgeons negotiated an alternate payment plan which is sort of like a salary. They were able to negotiate from a position of strength and got quite a sweet deal. When I worked in neurosurgery, it was a very busy and efficient room (s), always fully booked, with cancellations filled immediately. The list usually ran into the evening and cases on the weekends were the rule not the exception. That meant on the week you did neuro you worked quite long hours but made a nice wad of money. That was until they went on the APP. All of a sudden the neuro room ran until 1500 every day, there were gaps in the list and weekend or evening work became a thing of the past. The number of back surgeries, tumour "debulkings" and other heroic cases procedures plummeted. It was at the same time hard to argue that at a societal level, patient care was any worse than before they went on the APP. You could probably argue it was a little better.
It would be nice if physicians and society in general just did what really needed to be done because it was the right thing and not because there was some financial incentive involved but I am not holding my breath.
The one constant I have found during my medical career is that without exception people want to make the most money they can by doing the least work they can. This can also be extrapolated to organizations if you want. There are of course workaholics that we all know but they benefit in other ways. Quite frequently because of the volume of work they do, they are well compensated (including taking advantage of after hours incentives by doing their elective cases after hours) and by working hard they avoid stressful family situations( not to mention opening up a perfect cover for the extramarital affairs so many of them seem to be involved in). Quite frequently physicians and other people perceived as workaholics, don't work all that hard, rather they expect other people to work hard for them.
It should be no surprise that if you offer carrots to intelligent psychopathic individuals (which describes 90%) of doctors, that they are going to find a way to get those carrots in the most efficient way possible. About two years ago for example our medical society negotiated a complex care fee for family doctors. The idea was that for every patient who met certain criteria, they would be able to once a year bill about $200 for the care of the patient. An incentive for doctors who kept patients with chronic problems keeping in mind the many aspects of the care of these patients don't fit fee for service codes. The economists who reviewed the fee estimated the average family doctor would bill 7 of these a year. Within a month or some many family docs were billing 7 of these a day.... every day. There are ways of auditing this which they probably didn't anticipate and of course auditing is never a pleasant task. I somehow don't think the poor patients with the chronic conditions are getting any better care from their doctor despite him getting the extra $200 a year. (Some of them I suspect probably never realized they had a chronic problem).
This of course reminds me of a story somebody told me. A long time ago our province brought in a fee for "lifestyle" counselling which paid about twice what an office visit paid. Very quickly they noticed one doctor was billing 40 of these a day. Somebody called him and asked him how he was able to do this. He told them that at the end of the visit he would say, "try to stop smoking". This fee no longer exists.
The fee for service system is of course a mini pay for performance scheme where the more patients you get through, the more you get paid. This doesn't of course say anything about quality of care but at the very least patients do get seen. In fact often the best care is no care at all, and there doesn't seem to be a way of paying for that.
About 7 years ago our neurosurgeons negotiated an alternate payment plan which is sort of like a salary. They were able to negotiate from a position of strength and got quite a sweet deal. When I worked in neurosurgery, it was a very busy and efficient room (s), always fully booked, with cancellations filled immediately. The list usually ran into the evening and cases on the weekends were the rule not the exception. That meant on the week you did neuro you worked quite long hours but made a nice wad of money. That was until they went on the APP. All of a sudden the neuro room ran until 1500 every day, there were gaps in the list and weekend or evening work became a thing of the past. The number of back surgeries, tumour "debulkings" and other heroic cases procedures plummeted. It was at the same time hard to argue that at a societal level, patient care was any worse than before they went on the APP. You could probably argue it was a little better.
It would be nice if physicians and society in general just did what really needed to be done because it was the right thing and not because there was some financial incentive involved but I am not holding my breath.
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