silver (04/02/83)
The following excerpt is from an AP story in today's paper. I quote a small part of it to provoke conversation. "BOSTON (AP) - Workers don't get paid if they mess up a paint job, and physicians should not be compensated if their patients fail to get better... "Dr. Gil Hauer Santos is recommending that doctors be denied payment unless their work makes a positive contribution to their patients' health... "Surgeons whose patients die or do poorly... would be forced to improve or give up surgery..." A novel idea, yes? Make the medical profession more accountable by paying for RESULTS, not for SERVICES. Of course, it might be harder to get a doctor to deal with the seriously ill. What do you think?
soreff (04/02/83)
I don't think that trying to evaluate a physician's skill on a case by case basis would work very well. Too many factors vary from case to case. Perhaps if some organization (insurance companies spring to mind) kept records of recovery rates of patients of particular doctors, they could advise patients with particular diseases to avoid particular doctors. If records of diagnoses (and autopsy results) were also maintained, then corrections could be made for how seriously ill the typical patient of any given doctor was. This would have the additional advantage of inducing physicians to specialize on types of diseases that they are particularly good at treating. Success in treating disease A combined with failure in treating disease B should lead to more referals of patients with disease A and fewer with disease B, rather than just averaging the total survival rates. Comments? -Jeffrey Soreff (hplabs!hplabsb!soreff)
mmt (04/03/83)
A long time ago I read that somewhere doctors are paid according to the health of their community, not by its sickness. In other words, if many people are seeing the doctor, the doctors get paid less, so it is in their interest to keep people healthy. This scheme has its problems (I won't see you, you aren't ill enough), but it might be worth a thought. It at least contrasts well with the idea of going for the most expensive possible medicine, keeping people coming back for unnecessary procedures, and so forth. I'm not suggesting that many doctors do this, but the temptation must be there. Certainly the probability of surgery for particular problems can vary dramatically across hospitals in a particular region, depending on the doctors' ideas, so it is clear that the use of a procedure is not determined uniquely by the problem. Maybe we would have a healthier community at less cost if doctors got some kind of premium for health as well as for sickness? Martin Taylor PS This idea REALLY pays the doctors for services rendered. Their true service is in ensuring that they have to do little.
jj (04/03/83)
I hate to be rude and uncaring, or to seem that way, but the idea of paying doctors only when they succeed seems to be a prime way to encourage euthanasia, and to get rid of the elderly. (PLEASE NOTE THAT I DO NOT WANT TO DO THAT!!!!!!) As a doctor, whos income depended on only successful treatment, and who had to swallow the cost of unsuccessful treatment, I wouldn't be willing, nor would I be able, financially, to handle any difficult cases unless I could raise my fee for successful cases enough to compensate. The results would be either that all seriously ill patients would die from lack of care, which is tatamount to murder. <I am NOT talking about right to die cases here, just about people with ruptured appendices, <is that the right plural?>, perforated ulcers, and the like, in which a otherwise perfectly healthy person has a serious life threatening condition that will result in death in a significant fraction of cases.> or that the cost would rise for survivors, until the same amount, or more, is received by the doctor. The elderly, of course, would be the most threatened, since elderly people in general are greater risks, and doctors would be taking their own life, pocketbook, and practice into their own hands any time they tried any surgical or heroic measures on an elderly patient. This cost, of course, would be born by the people who were treated successfully, since society would not allow physicians to reject difficult cases. In short, the result would either be a cessation of medical care for those in the most need of it, or a tax upon the healthy and young to care for the unfortunate, unhealthy, and elderly. In the first case, people die from neglegence, and in the second case, all incentives to perform in an effective or efficent manner are removed, people are still likely to die, the cost of medical care will rise immensely for those who survive and make their life impossible, and create even more hostility between the young and old, rich and poor(who would be even less able to afford care even when it would be successful), etc. I respectively submit that society needs none of these additional problems. I will grant that insurance does financial levelling, however, participation in an insurance plan is under the person's control, and furthermore does not remove all incentive for effective and efficent treatment. Furthermore, in the long run, the result will be that payment will be guaranteed for all patients, but the cost will be born by a few, and then (from necessity) supported by a levy or insurance plan to aid the survivors. I don't think it CAN work.
mark (04/04/83)
Don't some lawyers get paid according to whether they win or lose the case? If you win, they get x% of the award, if they lose they get nothing. Yet there are public defenders around for the indigent, and there are lawyers who are hired by the hour or by the case at a fixed rate. There might be some parallels here.
perelgut (04/04/83)
I don't think that I could condone the concept of paying doctors only for
results.
First, how could you convince a doctor to handle an especially tricky
case. No one would dare treat cancer. Who would even risk experimenting with
cures for cancer since there would be no demand for anything less that a 100%
guaranteed cure? Would you get unscrupulous operators who accept cash payments
to handle terminal or tricky cases?
Second, who could judge the results and determine whether or not the
patient gained from the treatment. A doctor could claim that the patient would
have suffered much more without the treatment, and who could really say
otherwise.
I am all in favour of discussing alternative methods of paying for medical
services. The concept of paying by community health is interesting but not
practical. Who judges health, what happens if many doctors serve a single
community, etc. How about not allowing doctors to charge anything at all.
Only pay all doctors a set fee with merit payments based on internal ranking
within their professional association. I realize that this could lead to
internal politics and such, but I think we might be able to solve these with
some effort.
What about conscripting all doctors and paying them a set salary plus
supplying them with government paid-for housing and some allowance. If the
perks were made large enough, this one might work.jwb (04/05/83)
The concept of flat fees for health care underlies "Health Maintenance Orgini- zations". Some of these have been very successful (i.e. Kaiser-Permanente on the west coast). I think most people are aware of the concept--you pay a fixed fee and the origanization agrees to keep you well, including contracting for specialized care if necessary. These systems work best with a large subscriber base (>50,000) which has been the problem with many of the ones started in inner cities. Well run, HMO fees can be comparable to Blue Cross-Blue Shield. Poorly run they can be expensive and the care not very good. Incidently the federal programs, Medicare and Medicaid are going toward a new system of payment to hospitals. They will establish a standard length of time a patient should stay in the hospital for a given diagnosis and pay for that. If hospitals get the patient out earlier, they keep the money (although the lengths of time are refigured periodically). If a patient stays in longer than the standard time, the hospital gets no more money. It's too early to tell if this system is going to work. Jack Buchanan ...duke!mcnc!jwb
pn (04/06/83)
I heard that Rolm Corp., who have been said to be more like HP in treating their people well than HP, is offering their employess a new form of dental care, where the dentists are offered a flat fee per year. The idea is preventative care, even if initially expensive, will pay off in the long run for participating dentists. One family even got orthodontic care included in the coverage. ~v Medical and dental care aren't comparable because perfect dental health is attainable these days while many diseases are incurable, but I thought this would be of interest.
bcw (04/07/83)
From: Bruce C. Wright @ Duke University Re: "Doctors should be paid according to services rendered" Here at Duke there was a database of cardiac patients and their followup histories established about 14 years ago. One of the concerns expressed by some of the doctors at the time was that something of this exact nature would develop. Some of them refused to enter their patients in the common database for this very reason ... Bruce C. Wright @ Duke University
bernie (04/07/83)
The idea of paying doctors according to the results they produce has a lot of merit to it, as well as some obvious problems. The advantages are pretty obvious; doctors have more of an incentive to seek out an effective cure, rather than just a treatment that deals with symptoms. Patients don't wind up spending vast sums of money on "cures" that don't work. The overall cost of medical treatment goes down. The disadvantages are a little less obvious. Doctors would hesitate to try novel approaches to curing disease, since those approaches may not work and hence be a waste of their time and resources. Also, they would not want to treat terminally ill patients at all (since they are doomed to failure from the outset). However, the idea mentioned by a previous poster (government support of doctors, all of them getting a fixed wage) would be an outright disaster, dramatically increasing the cost of medicine (to taxpayers) and reducing the overall quality of health care. So what, then, is the solution? My suggestion is to generally pay doctors according to the results they produce, but give doctor and patient the option of negotiating some other arrangment if there are treatements that may or may not work and both agree to give them a try. --Bernie Roehl ...decvax!watmath!watarts!bernie