Sunday, January 31, 2010

Fee-for-Service or Salaried Medicine? Part I

I am qualified to opine on physician compensation formulas, because I’ve spent hard time on both sides of the payment seesaw. For the first 10 years of my career, I was on salary. We were told, however, that we could earn productivity ‘bonuses’, but these rewards were trivial. An ‘employee of the month’ parking spot near the entrance would have been worth more, especially during the frigid Cleveland winters.

After 10 years, I moved over to the dark side, where I was paid for each service I provided. In Part I this week, I present pros and cons of salaried medicine. I suspect that I've overlooked some of the advantages and drawbacks of paycheck medicine, so  I hope that readers will correct my errors and omissions.

Good Stuff About Paying Gastroenterologists a Salary
  • Lowers health care costs by underpaying specialty physicians
  • Eliminates financial conflicts of interests. The colonoscope is not a capitalist tool.
  • Reduces unnecessary medical procedures as gastro docs would rather read The New York Times than scope for free. This not only increases gastro docs’ knowledge of the world, but also reduces job cuts at the Times and other newspapers facing financial challenges.
  • Lowers medical costs by reducing the volume of GI consults, since primary physicians know there is a high threshold for pulling the ‘scope trigger’.
  • Dinner with the family every night since salaried physicians turn their beepers off at the appointed hour.
  • Strengthens character by shielding salaried specialists from greed and other sins and temptations.
  • Creates more relaxed and rested GI specialists. Every minute of alloted leisure time is taken. Hey, the boss is paying! I know this because I've been there.
  • No need to devote even 2 neurons to payroll, overhead and cash flow issues.
  • No hustling for patients.  For me, this was the sweet spot of salaried medicine.

Crummy Stuff About Paying Gastroenterologists a Salary
  • Eliminates an important incentive to increase performance.
  • Patients often told that the schedule is full. Why squeeze in a patient ?
  • Patients with acute issues are often directed to urgent care centers or emergency rooms by staff personnel, or physicians, who have been affected by the shift work mentality of a salaried culture.
  • Creates fun turf conflicts when salaried gastroenterologists spar with salaried primary care physicians over which of them should go the to ER to see a diverticulitis patient at midnight. Since neither will get paid for the encounter, each graciously volunteers that the other do the doctoring deed. Here’s a hypothetical conversation that every emergency room physician has heard repeatedly.
Internist: “Diverticulitis is a pure gastrointestinal condition and you should admit the patient STAT!”

GI Guy: “I did an internal medicine residency also. We never dumped on our specialists. Aren’t you an internist? Would you ask a pulmonary specialist to admit a patient with a cough? Would you ask a nephrologist to admit a patient with a urinary tract infection? Are you a real doctor or a triage machine?”
  • Loss of professionalism when medical policy and employment edicts are issued by ‘suits’.
  • Measurement, monitoring and tracking of absurd performance standards that can be used to provide ‘bonus’ payments to compliant physicians. Read: You will be docked if you don’t fall in line.
To my salaried colleagues, please don’t grab a pitchfork and head to Cleveland. Many of you are excellent physicians and don’t sit around reading The New York Times like I do. Remember, for half of my career, I was one of you. There are clear advantages to the health care system when financial conflicts of interests are reduced. Nevertheless, I maintain that financial incentives can increase quality and performance in any occupation, and that the profit motive can be a force for good. Conversely, employees who are paid by the hour or by the week, may be less likely to provide the highest levels of personal service, although I admit that this is a generalization.

When I enter a hardware store that is a family business, I am greeted at once by smiling human beings who are anxious to assist me.  When I enter a big box warehouse retail outlet, I have to hire a private investigator to track down an employee who is under cover, hoping that I will at least be told the longitude and latitude of my desired purchase. 

Fee-for-service medicine is often demonized, but is it really the enemy?

Next week, Part II: the good, the bad and the ugly of coming off salary.

Sunday, January 24, 2010

Why Did Coakley Bomb in Massachusetts? Ask Aesop

One day a hare saw a tortoise walking slowly along and began to laugh and mock him.
The aftershocks from the political earthquake that just occurred in Massachusetts will extend to the first Tuesday this November. Democrats are dazed and reeling from what should have been their easiest electoral victory in the nation. Martha Coakley, their candidate, was 30 points ahead in the race only weeks ago. Look up the word complacency in the dictionary and you may see her photograph alongside the definition. [For younger Whistleblower readers, a dictionary is a large volume that fossilized folks like myself still consult for word definitions and correct spellings.]
The hare challenged the tortoise to a race and the tortoise accepted. They agreed on a route and started off the race.
After Coakley prevailed in the primary election by 19 points on December 8th, she vanished. I guess she felt entitled to a Senate seat that Democrats controlled for nearly 6 decades. While she was AWOL, Scott Brown plodded on, putting one foot in front of the other, and pursued the strategy that most successful politicians advocate – meeting voters. I’m no political expert, although I did handily win an election to the illustrious office of Ninth Grade Vice President several decades ago. I suspect, however, that most voters want candidates to actually campaign and earn their support.
The hare shot ahead and ran briskly for some time.
The GOP national leaders wisely stayed on the sidelines. The Democratic leadership unwisely made the same choice. Only at the race’s conclusion, as Coakley was leaning over a cliff, did President Obama try to apply a Band-Aid to a corpse. The President and his advisors, in a John Kerryesque moment, were against coming to Massachusetts to stump for Coakley, until they were for it.
Then seeing that he was far ahead of the tortoise, he thought he'd sit under a tree for some time and relax before continuing the race. He sat under the tree and soon fell asleep.
The President made fun of Scott Brown’s truck. Even as a high school candidate for higher office, I knew that you never, ever make fun of someone’s truck. I’m sure that when the President uttered these words, that David Axelrod had an apoplectic reaction. This might be even worse than referring to voters as 'bitter clingers of guns & religion'. It’s okay to make fun of a candidate’s BMW, or even a Lexus, but don’t touch the pickup.
The tortoise, plodding on, overtook him and finished the race.
Those who study campaigns, or should study them, will be studying this one for a while. This was a political bombshell. As expected, the blame game is in full operation. While a circular firing squad seems appropriate, some are scapegoating Republicans as the ‘Party of No’ in the wake of their electoral debacle. If I were a Democrat, I would suggest a different strategy. Coakley didn’t lose because of the nefarious ‘Party of No’. She lost because liberal Massachusetts, a Democratic bastion, became the ‘Electorate of No’. They soundly rejected the current versions of health care reform. Most blame Coakley. Many blame the Democratic Party. Some blame the GOP. I blame the health care reform plans and the opaque and tawdry process that created them. Those whom we elected to serve us nearly succeeded in forcing a plan that most of us reject right down our throats.  If they wouldn’t gulp it down in Massachusetts, they won’t swallow it in the rest of the country either.
The hare woke up and realized that he had lost the race.
Huh? What happened?

Slow and steady wins the race!

Sunday, January 17, 2010

Should We Pay For Organ Donation?

Could this man increase organ donation?

Choose the best answer.

To stimulate organ donation, we should provide organ donors with:
  • Cold, hard cash
  • Upgrades to business class on any flight within the continental United States for 1 year
  • College tuition discounts for up to 3 children
  • Income tax relief
  • First row Bruce Springsteen concert tickets
  • A certificate of appreciation
There is a reason that we don’t ask families of kidnapped victims what our policy should be with regard to hostage negotiations. Any family in this situation, including mine, would favor paying the ransom. While this would serve an individual family’s interest, it would conflict with the public’s interest as it would encourage more kidnappings. Thus, the greater good would be compromised.

Similarly, families seeking an organ for a loved one are not the proper source of policy recommendations for organ procurement. Understandably, they want an organ at any cost. Certainly, if my child needed a liver to survive, I would not want to hear that saving him would amount to an ethical crime against humanity. And, I might not care. For this reason, medical ethical policies should be carefully crafted by thoughtful and dispassionate individuals who can approach the issue from a broad societal perspective. Of course, those who have a personal stake in the game should have a voice at the table, but they should serve as an advisory and informational role. Their views should be considered, but not necessarily adopted. These are heartwrenching and controversial issues, particularly when an individual’s plea for life is deflected off an ethical firewall.

Is purchasing tissues and organs a worthy idea for society? Would it violate ethical standards against exploitation? Would it injure the ethical principle of justice?

Many argue that buying organs should be permitted, just as affluent folks can purchase cosmetic surgery, luxury cars or Caribbean vacations. If they can afford to purchase a kidney from a willing seller, they argue, why shouldn’t the transaction take place?

Organ shortages have resulted in a reconsideration of ethical procurement practices that were heretofore prohibited. Many fear that folks at the end of life are already viewed as organ donors in an effort to save others who are awaiting organ transplantation. One way to increase the donor pool with the stroke of a pen is simply to ‘modify’ the defintition of death. In the past, dead meant brain death. Nowadays, cardiac death, a new & improved definition of the end of life, has greatly increased organ donor supply. Is this definition-creep motivated by a desire to increase the donor reservoir? Is this the right thing to do? It takes little imagination to foresee how slippery and vertical this slope can become.

Sick and desperate people awaiting organs have rights too. We must be extremely cautious that our zeal to protect society’s rights is not outweighed by their right to life.

It is illegal to purchase organs in the United States, but other countries have different policies. The Wall Street Journal, John Goodman’s Health Policy Blog and NPR reported that Iran will pay citizens to donate and, as a result, they have no organ shortages. Singapore organ-seekers pay tens of thousands of dollars for an organ. Some nations, such as Sweden and Spain, presume consent to donate organs, unless the invidual has actively opted-out of the program. In the United States, there is no presumed consent. Israel, in response to a low organ donation rate, has just launched a program to reward willing donors by giving them priority should they ever need a transplant. I just learned about an organization here in the United States called LifeSharers, whose members pledge to donate organs and to give fellow members in need priority access of these organs. The organization charges no fee and currently has over 13,000 members.

Maurice Bernstein queried on his provocative Bioethics blog if it should be legal to procure organs from dead individuals without consent from the patient or family. There is a long thread of thoughtful comments from readers.

I think we should provide more incentives to donate, although I do not advocate buying and selling organs on the free market. This would lead directly to economic and physical exploitation of our most vulnerable people. I also vigorously oppose bending the definition of death for the purpose of saving others. One life is not worth more than another. Of course, it’s easier to make principled and categorical statements as a blogger. But, don’t ask me for my high and mighty opinion if my child is on the transplant list. I’d pay the ransom.

What are your thoughts to promote organ donation within the boundaries of medical ethics?

Sunday, January 10, 2010

Tort Reform: A Plaintiff’s Lawyer’s View

ScalesCA2C09S1 Whistleblower readers know my views on the medical liability system. I have devoted more posts to tort reform than to any other issue. Readers, whose blood pressures are adequately controlled, are invited to review those posts on this blog under the Legal Quality category. (I was tempted to name the category Legal Abuse, but wanted to keep the category names consistent.)

I review many legal blogs, most of which are ideological rants against physicians that express steadfast fidelity to the current system. If the medical community were as united and focused as the trial lawyers are, our future would be more sanguine.

Gerald Oginsky is a plaintiff’s attorney who sues physicians. I have never met him and he has never sued me. Gerry left a comment on one of my Legal Quality posts, which demonstrated fairness and reasonableness. This lured me to his blog, where these same two qualities are evident.

For this week’s Whistleblower, I am sharing a recent posting from Gerry’s blog. While the substance is not breaking news, it is unique as it is authored by an attorney who sues physicians. It is refreshing to dialogue with a lawyer who can express views and understanding beyond his own parochial interest. 

With his permission, here is his post.

With all the talk about health reform today, and proposed 'tort reform' by Republicans together with sensationalized lawsuits in the newspaper today, it's no wonder that many people think that they're "Entitled" to money just because they had a bad outcome.

Our society is conditioned to think, rightfully so, that if they've been wronged, then they have a right to go to court and obtain compensation from the person or company that caused them harm.

When it comes to medical malpractice lawsuits in New York, do you really think that your doctor woke up that morning and said to himself (or herself) "Who can I injure today?" Unlikely. Instead, what we experienced lawyers regard as a departure from good medical practice, may, in the mind of a physician be simply a bad judgment for which a patient had a poor outcome.

Remember, not every bad outcome represents malpractice. I often tell potential clients when they call that "Just because you suffered a complication or a bad outcome, does not necessarily mean that you have a valid case. You may, but you need to know how an experienced lawyer evaluates a case like yours."
Many people who call an attorney automatically think that because the doctor had a bad bedside manner, or the patient is now worse off than when they had the treatment, then something must have been done wrong. That type of thinking is often not accurate.

Also, contrary to popular belief, the majority of good medical malpractice lawyers refuse to take most cases because either they lack merit, or the damages (injuries) the patient suffered is not significant. Our role has been described as a gatekeeper, keeping out most cases that do not belong in the legal system.
Do some cases get through that should not? Yes. Do some over-zealous attorneys take on a case that should not be brought? Yes. But this extremely small percentage is statistically insignificant and the jury system works in those cases by discarding those that lack merit, and rewarding compensation to those that rightfully deserve it.

Sunday, January 3, 2010

Health Care Reform Musings from Dixie

Blogging now from South Carolina, the cradle of the Confederacy.  This was the first southern state to secede from the Union on December 20, 1860.  We all remember the portentous headline from the Charleston Mercury that rattled the nation and President-elect Lincoln, who was still 3 months away from taking office.  Prior to his inauguration, 6 sister states would join South Carolina to form a confederacy.  They would try by force to form a new nation.  And we think President Obama has a heavy load?
I learned years ago, during one of my yearly historical sojourns, that strong echoes of the Confederacy survive. We came to a Charleston, South Carolina to a Bed & Breakfast and were greeted by the proprietress. We exchanged pleasantries and told her we were anxious to see some of  the area’s civil war treasures.  With a steely demeanor, she admonished me. “Round here,” she said, “we call it the War of Northern Aggression.”  Her statement was much more powerful heard in her slow, southern drawl, than read here.  I’ve never forgotten the moment.  Words matter.  History still lives.

Thanks to Lincoln and some determined Union generals, and perhaps to divine providence, the government of the people, by the people, for the people, did not perish from the earth.
While the nation today is indivisible, as kids used to recite daily in school each morning, the country is highly polarized. While there won’t be shots fired at Fort Sumter any more, there remains a surfeit of seemingly irreconcilable conflicts that bitterly divide us.  Our most vexing issues – war in Afghanistan and Iraq, abortion, global warming, civil liberties, domestic economic policy, racism and church-state issues – all generate vitriol and hostility in the public square.

And then came health care.  Whistleblower readers know of my skepticism and suspicion about pending health care reform (HCR) legislation.  Despite my own partisanship, I have been struck by how raw and divisive this issue is, and will surely be for years to come.  The votes in the House and Senate demonstrate this.  Nancy Pelosi had barely a vote to spare, and Harry Reid had none.  The Democrats determined that they had no legislative partner on the other side, so they forged ahead on their own.  The GOP now threatens to use the Democrats’ legislative success against them in 2010 and 2012.  Instead of invoking Lincoln’s philosophy from his 2nd inaugural address, with malice toward none, with charity for all, we all entered the health care reform as gladiators.  As a result, there are many good ideas that are casualties stranded on the legislative battlefield.

Who’s fault is all this?  I’ll let the readers assign blame for this acrimonious and divisive process, and there’s plenty of it on all sides.  Judging by some comments received to my posts, I deserve a measure of responsibility also, which I accept.  Certainly, the public doesn’t have much confidence in the folks who are representing us.  Gallup poll results from last week report that Congress’s approval rating continues to soar at 25%.  Half of those polled believed that Nancy Pelosi and Republicans in Congress were ‘political losers’ in 2009.  Inspiring statistics.

Our words matter, as the innkeeper in South Carolina taught me. Indeed, many loaded terms have been hurled to scare, obfuscate, ridicule and attack. How would we describe the HCR conflict in Lincolnian terms?  Is it a Health Care Civil  War?  A War of Democratic Aggression?  A War Between the Parties?  A War to Free the Uninsured?  Is it really about health care or is it about political power and control?  Lincoln is lauded today for having included political rivals in his cabinet so that he could receive a diversity of advice (and, perhaps, neutralize the opposition).  What a refreshing concept.   It’s a shame we did not mimic this approach with health care reform.  Is Lincoln’s model of soliciting advice from adversaries merely a historical artifact to be studied, but is not relevant in our time?  Weren’t there good ideas from both sides of the aisle that could have been incorporated into health care legislation?   Apparently not.

For some issues, there can be no compromise.  Lincoln recognized that the nation could not be divided and survive.  He could not ‘split the baby in two’.  But health care reform does not pose an immediate existential threat to the nation.  We could have done it better.  Both sides plotted, strategized and blew up bridges.
South Carolina was on the wrong side of history.  And so are we.

Whistleblower is a year old.  Many thanks to the readers.