5 ms·

When possible, I prefer people who work for me to have incentives that are aligned with mine. PE-owned medical practices and even many private practices throw t

When possible, I prefer people who work for me to have incentives that are aligned with mine. PE-owned medical practices and even many private practices throw that out the window, with financial incentives to do procedures or run tests. I was talking to my wife’s obstetrician about this last week and he also feels strongly about it. He’s paid a flat salary and gets no financial benefit for a c-section vs. an induction vs. a conventional delivery. I’d like to keep it that way.

starcraft2wol 3y ago
> gets no financial benefit for a c-section I don't think that's typical anywhere. The incentives they face are less concrete. It may be more inconvenient or uncomfortable for the doctor. If something goes wrong and there is a legal risk, it's difficult to retroactively justify not immediately changing strategies.
- goodpoint 3y ago
  It's actually typical in some countries, and it's mean to avoid the conflict of interest around prevention VS selling treatments.
- Calavar 3y ago
  In the US, C-sections reimburse higher than vaginal deliveries across the board. What's changed over the years is who gets the extra money from the C-section. It used to be the physician, but nowadays it is increasingly the hospital. The incentive to do C-sections over vaginal deliveries is still there, but it's transforming into a population level incentive (i.e. is the hospital structuring staffing and workflow in a way that favors C-sections) rather than an individual one (i.e. is a particular physician very trigger happy with C-sections).
tryptophan 3y ago
Flat salary is an incentive to do the easiest option or least work. You can’t win with the incentive game. One nasty way that can manifest is to under test because if you don’t find anything you don’t have to do anything.
- syvolt 3y ago
  That seems infinitely better than the status quo. Having unnecessary procedures is much worse. With the former you can go to another doctor, with the latter they'll just run up your bill until you're broke or dead unless you're one of the exceedingly rare few who gets medical advice from multiple doctors (most can't afford that or do not have alternative in-network doctors).
- leoh 3y ago
  > You can’t win with the incentive game. I agree that incentives are frequently and perhaps typically exploited, especially when crafted carelessly or not iterated upon, as most incentives seem to be. I would be eager to contemplate a clinical outcome based incentive scheme.
  - raphman 3y ago
    Wouldn't this incentivise doctors to only accept cases with a high chance of quick success? Young child with cancer? Nope, not worth the risk. Patient with mental health problems? Takes too long, outcome not easily measurable. Obese patient with back pain? Let's do surgery instead of investigating and treating the root causes.
    - boondoggle16 3y ago
      No, this is way too simplistic. They can be judged on relative performance of cases. Just like schools, you can tell which teachers are good, even in districts with bad kids.
    - brentis 3y ago
      Came here looking for this angle. Seeing doctors now feels like talking to someone who has memorized an actuary-like table for the doctor's risk/reward versus patients benefit/outcome as in the past. Have a torn meniscus and given age is dumped into "excise meniscus tear" bucket. While Dr knows that shortens the path to knee replacement (which he no less pointed out on several occasions). Going to Dr. Now seems like you are a walking revenue center vs. patient in need. (ps. Many current accredited studies suggest repair attempt vs. removal)
pc86 3y ago
Physicians are absolutely reimbursed per procedure, per surgery, per test, etc. OB specifically has a higher concentration of employed doctors, but the hospitals are still reimbursed the same way, and these numbers are 100% taken into account when determining things like bonuses and promotions. But other specialties (like family med) are still dominated by private practices where physicians directly earn more by doing more. The balancing act of this is that oversight is (typically) by qualified medical professionals who can judge whether a given procedure, test, surgery, etc. was medically indicated or not.
- Calavar 3y ago
  > 100% taken into account when determining things like bonuses and promotions Eh, there's some truth to what you said but it's a bit of a stretch. For bonuses, it depends on specialty and practice. In my current job I have zero incentive structure, period. If by some miracle, zero patients showed up on my shifts over the course of an entire year, I would make exactly the same as if I averaged 20 patients per day. I also don't get any reimbursed for any of the procedures I do -- 100% of that goes to the hospital. This is an increasingly common compensation model in pretty much every nonsurgical speciality and even in a small number of surgical ones (Ob/Gyn, as you mentioned). As for promotions, I don't think that's true at all. First, physicians tend to have a very flat hierarchy outside of academics. (At many hospitals, you're either CMO, a department chief, or just some guy.) What this means, in my personal experience, is that promotion is such a remote possibility that it's something that 80 to 85% of physicians don't spend any time thinking about. Second, productivity is not a principle criterion for promotion. When a hospital or clinic promotes a physician, they take a large chunk of that physician's clinical time and replace it with administrative work. If you're trying to maximize revenue, your most clinically productive person is precisely the last person you want to do that with. > But other specialties (like family med) are still dominated by private practices Family medicine is definitely not dominated by private practices, at least for new grads. Private practice is quickly going extinct everywhere except for those specialties that have a high proportion of out-of-pocket payors (plastic surgery, dermatology, orthopedics) or those specialties where the demand is high but the supply is so thin that hospitals can find themselves battling with each other to sign contracts with the one of the few practices in their area (neurosurgery, otolaryngology, CT surgery in some parts of the country).
bradleyjg 3y ago
The supposedly not for profit hospital systems conglomerates are as rapacious as any robber baron. Nominal form is no guarantee.
chimeracoder 3y ago
> PE-owned medical practices and even many private practices throw that out the window, with financial incentives to do procedures or run tests. Quite the opposite. They tend to be under capitated contracts with insurers, which means they are responsible for the costs of services they provide, but receive a flat amount for reimbursements. This explicitly encourages underutilization of care.

starcraft2wol 3y ago

> gets no financial benefit for a c-section I don't think that's typical anywhere. The incentives they face are less concrete. It may be more inconvenient or uncomfortable for the doctor. If something goes wrong and there is a legal risk, it's difficult to retroactively justify not immediately changing strategies.

goodpoint 3y ago
It's actually typical in some countries, and it's mean to avoid the conflict of interest around prevention VS selling treatments.
Calavar 3y ago
In the US, C-sections reimburse higher than vaginal deliveries across the board. What's changed over the years is who gets the extra money from the C-section. It used to be the physician, but nowadays it is increasingly the hospital. The incentive to do C-sections over vaginal deliveries is still there, but it's transforming into a population level incentive (i.e. is the hospital structuring staffing and workflow in a way that favors C-sections) rather than an individual one (i.e. is a particular physician very trigger happy with C-sections).

tryptophan 3y ago

Flat salary is an incentive to do the easiest option or least work. You can’t win with the incentive game. One nasty way that can manifest is to under test because if you don’t find anything you don’t have to do anything.

syvolt 3y ago
That seems infinitely better than the status quo. Having unnecessary procedures is much worse. With the former you can go to another doctor, with the latter they'll just run up your bill until you're broke or dead unless you're one of the exceedingly rare few who gets medical advice from multiple doctors (most can't afford that or do not have alternative in-network doctors).
leoh 3y ago
> You can’t win with the incentive game. I agree that incentives are frequently and perhaps typically exploited, especially when crafted carelessly or not iterated upon, as most incentives seem to be. I would be eager to contemplate a clinical outcome based incentive scheme.
- raphman 3y ago
  Wouldn't this incentivise doctors to only accept cases with a high chance of quick success? Young child with cancer? Nope, not worth the risk. Patient with mental health problems? Takes too long, outcome not easily measurable. Obese patient with back pain? Let's do surgery instead of investigating and treating the root causes.
  - boondoggle16 3y ago
    No, this is way too simplistic. They can be judged on relative performance of cases. Just like schools, you can tell which teachers are good, even in districts with bad kids.
  - brentis 3y ago
    Came here looking for this angle. Seeing doctors now feels like talking to someone who has memorized an actuary-like table for the doctor's risk/reward versus patients benefit/outcome as in the past. Have a torn meniscus and given age is dumped into "excise meniscus tear" bucket. While Dr knows that shortens the path to knee replacement (which he no less pointed out on several occasions). Going to Dr. Now seems like you are a walking revenue center vs. patient in need. (ps. Many current accredited studies suggest repair attempt vs. removal)

pc86 3y ago

Physicians are absolutely reimbursed per procedure, per surgery, per test, etc. OB specifically has a higher concentration of employed doctors, but the hospitals are still reimbursed the same way, and these numbers are 100% taken into account when determining things like bonuses and promotions. But other specialties (like family med) are still dominated by private practices where physicians directly earn more by doing more. The balancing act of this is that oversight is (typically) by qualified medical professionals who can judge whether a given procedure, test, surgery, etc. was medically indicated or not.

Calavar 3y ago
> 100% taken into account when determining things like bonuses and promotions Eh, there's some truth to what you said but it's a bit of a stretch. For bonuses, it depends on specialty and practice. In my current job I have zero incentive structure, period. If by some miracle, zero patients showed up on my shifts over the course of an entire year, I would make exactly the same as if I averaged 20 patients per day. I also don't get any reimbursed for any of the procedures I do -- 100% of that goes to the hospital. This is an increasingly common compensation model in pretty much every nonsurgical speciality and even in a small number of surgical ones (Ob/Gyn, as you mentioned). As for promotions, I don't think that's true at all. First, physicians tend to have a very flat hierarchy outside of academics. (At many hospitals, you're either CMO, a department chief, or just some guy.) What this means, in my personal experience, is that promotion is such a remote possibility that it's something that 80 to 85% of physicians don't spend any time thinking about. Second, productivity is not a principle criterion for promotion. When a hospital or clinic promotes a physician, they take a large chunk of that physician's clinical time and replace it with administrative work. If you're trying to maximize revenue, your most clinically productive person is precisely the last person you want to do that with. > But other specialties (like family med) are still dominated by private practices Family medicine is definitely not dominated by private practices, at least for new grads. Private practice is quickly going extinct everywhere except for those specialties that have a high proportion of out-of-pocket payors (plastic surgery, dermatology, orthopedics) or those specialties where the demand is high but the supply is so thin that hospitals can find themselves battling with each other to sign contracts with the one of the few practices in their area (neurosurgery, otolaryngology, CT surgery in some parts of the country).

bradleyjg 3y ago

The supposedly not for profit hospital systems conglomerates are as rapacious as any robber baron. Nominal form is no guarantee.

chimeracoder 3y ago

> PE-owned medical practices and even many private practices throw that out the window, with financial incentives to do procedures or run tests. Quite the opposite. They tend to be under capitated contracts with insurers, which means they are responsible for the costs of services they provide, but receive a flat amount for reimbursements. This explicitly encourages underutilization of care.