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Pay-for-Performance and Accountability

John W. Rowe, MD
[+] Article and Author Information

From Columbia University, New York, NY 10032.


Potential Financial Conflicts of Interest: None disclosed.


Ann Intern Med. 2007;146(11):824-825. doi:10.7326/0003-4819-146-11-200706050-00022
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Physicians Unions: the only antidote to pay for performance
Posted on June 15, 2007
Edward J. Volpintesta
No Affiliation
Conflict of Interest: None Declared

The author is correct to say that the only credible way to pay for medical care is for the purchaser(patient)to pay directly to the provider(doctor or health care organization) and not through a third party.

Ideally, doing so would allow patients to develop more realistic relationships with their physicians and others within the health care system.

How? First, it would make them more aware of the costs of medicines and procedures; and make them less likely to ask or demand the latest procedure or medication on the market. And since patients would be more hesitant about demanding the "latest" there would be less incentive for medical device manufacturers to invent new machines with only incremental improvement over existing ones.

Even drug manufacturers would have to curtail some of their research on "new" drugs, of which some have questionable value.

The point is that since insurance is available, it acts as an incentive to the whole system to do more, invent more, consume more. There is no end to a system that feeds itself on this philosophy. One could state that having insurance is one reason why most doctors are drawn to specialization: since there is money available for doing procedures why not choose a career that pays well for doing them, especially when a career in primary care which is, practically speaking, "procedureless" is at such a disadvantage.

The problem with having patients pay physicians directly is that health care can be costly and most people need some sort of insurance to protect themselves against bankruptcy. But as experience shows, insurers respond by raising their premiums and co-pays. Soon,paying for insurance will be just as costly as paying for health care directly!

Making matters worse is the legal imperative that all physicians face: having to "do everything". Regardless of guidelines and evidence- based practice, every patient will be treated differently because they are individuals. And no physician would want to expose himself to a lawsuit frivolous or otherwise, by basing his treatment solely on good clinical guidelines. Even if his treatment stands up in court, very few doctors are willing to take that chance, regardless of what they say in private. Clearly, all doctors put a little defensive medicine into what they do. Even it adds little to the patient's care, it allows doctors to sleep peacefully at night.

Since health insurers have the upper hand in health care, since they are paying for it and patients genereally are not willing to do without it, physicians will have to live with decreasing returns on their labors.

This is the reason why many doctors are demoralized; and for those who have been in practice for a few decades and have experienced a period of fulfillment, even if it was short-lived, there is growing resentment.

Perhaps if physicians had unions, they could leverage their strengths and gain meaningful reform. Right now many of them they are being compensated with just enough to carry on a moderately comfortable life style. Even so, they are tiny parts in a big machine, and the real recipients of their labors, are those who control the machine: the insurers.

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