However, if there is no discernable tradeoff, many docs would (as you say) be unhappy and less productive on a salaried basis.

On the other hand, the fee-for-service does have a lot of problems too: cost-control issues, does not value the time of the doc-just the diagnosis, and conflict-of-interest issues w/AMA owning the CPT codes.

So I’ve come up with a solution: http://drbrenner.blogspot.com/2009/06/medicare-reform-part-3-new-model-for.html that is based on an hourly base that is adjusted up for more years of training,completion of CMEs, experience etc…and also complexity of patients (e.g. neonatal and elderly, HIV). This values the time of doctors, allows them to focus on complex/chronic disease patients, and has the added benefit of making patients happy and cost-wise is self-limiting (only so much time available) and on my blog you can see how I propose to prevent abuse of this system.

While you and others make fine arguments against ideas, I’d like to see more people in medicine proposing possible solutions.

I would guess much of the interdisciplinary activity has more to do with efficiency and billing than any great medical model, although the medical successes are impressive.

Steve Lucas

I trained at both an academic university and a VA hospital. The culture of care at the VA was limited by the slowest common denominator. The support staff (nurses, techs, administration) all took the path of greatest resistance. And things were painfully slow. If you were a lazy doc by nature, you loved the VA. If you were a hard working doctor, you hated it. And it rubs off on you after a while. Many VA only docs were much lazier then their VA and University docs. You get used to doing less

That’s not to say that salaried only is bad. Salaried can work, if you have a culture of excellence and doctors, nurses and all others foster that excellence. That’s really hard to do if you pay poorly and expect excellence. But it is possible.

Still, the salaried model is not my choice. I would far prefer a model that paid doctors well to practice quality episodes of care AND work hard. You can bundle episodes of care that gives doctors the incentive to communicate, think about their decisions to offer the appropriate evidence based therapies, not just more therapies. AND it gives doctors a chance to profit from the cost effective nature of the decisions they make AND encourage them to see more patients by becoming more efficient in their practice.

If I could offer great care in a bundled approach and see 2000 patients a year, I should earn less than I would If I saw 3000 patients a year in a bundled system of care. BUT I shouldn’t earn more to see 3000 encounters in fee for service when only 2000 was required on those in a fee for service.

While some FFS doctors may be greedy, I think a bigger component of the uncontrollable health care inflation has to do with a lack of accountability. It’s just easier to do more than it is to think about whether your recommendation is a cost effective approach to the problem in front of you. If doctors cannot consider the cost of their quality care, then we will never find a way to slow the growth of our care. Because WE are the ones ordering all the tests.

I was used to a fast-paced clinic environment so I would see 20-25 patients per day plus having inpatient responsibilities. The Chief called me in and told me I was making the other docs look bad because most of them were seeing one-third fewer patients. So instead of expecting the others to increase productivity, I was told to slow down. Meanwhile the waiting times for a new patient were 3 months. I just shook my head and walked away mumbling.

No thanks. I’ll take the incentive-based systems every single time. Waaaaaay easier to get patient taken care of.