Lets talk about merit pay from a doctor's point of view....

[busymom]

I know it will be unpopular...because as a matter of point, doctors earn more than teachers (of course they do 4 additional years of schooling and 3-10 additional years of residency and fellowship training, have ~150,000 in student loans and pay exhorbitant malpractice rates ...) but here it is (at the request of someone in another thread).

Physicians in the internal medicine practice here are now paid and judged (as being good or bad doctors) by insurance companies and dr. rating agencies based on things like their patient's a1c levels. If you are a diabetic patient but don't do a super-good job of controlling your blood sugar by exercising and eating right, think twice. Your doctor will be dinged, paid less,will get a poor rating and in the case of the doctors here, the companies will post a quarterly "doctor quality rating" in the local newspaper. There are some doctors who simply are now making it difficult for their less compliant diabetic patients to get an appointment in hopes that they will go elsewhere and ruin someone else's ratings.

There is one doctor in the group who is probably the best clinician. She also takes a great deal of time with her patients and is very thorough. She regularly sees her name at the bottom of the list of "good doctors" though because she doesn't abandon her patients or make it harder for them to get appointments. She suffers for this in measurable ways though, and it is wrong.

The trend is now moving to judging doctors based on their patients smoking and obesity in similar ways....this means that the more overweight patients or smokers that you have, the worse your quality rating will be as a doctor. The idea behind this is that a GOOD doctor will help their patients quit smoking/lose weight, etc. Forget personal responsibility, I guess.

Also, my husband (who regularly sees patients w/o insurance and does not bill them in many circumstances) has to PAY out of his pocket for translators for patients...as do other physicians. This means that if you come into the office and have medicaid (that will only pay about $17 for your visit anyway...not enough to pay for him to read through your chart, familiarize himself with your illness, take a thorough history and listen to you and examine you and then come up with a treatment plan, and pay for his nurse, the electricity, etc) he may have to pay $200 out of his pocket to have someone come in and translate.

Obviously, accepting non-english speaking patients is becoming very unpopular.

The newest thing? Medicare doesn't want to pay for treatment for infections that come back after a patient is discharged from the hospital. So...if you leave the hospital and stop taking your antibiotics, or....for some reason the infection returns, the hospital and doctors will not be compensated.

The result of all of these changes is of course that doctors slowly will just not want to see people who are overweight, smoke, have uncontrolled diabetes, don't speak english or...may end up being not very compliant.

It really affects patient care and makes a lot of doctors feel unhappy because most of them really care about their patients and want to help them/treat them and feel resentful of being judged as less than simply because of the bizzarro rating system.

There's that perspective...

[frazzled]

1. Obama's proposal is not about merit pay tied to student performance

This is a really important point. What he proposed yesterday was enhanced benefits for teachers who are judged (by peers, superiors, parents, students) to perform well and be especially effective in the classroom. It will reward creativity, teachers who motivate and engage students, etc. Student score outcomes are not the only, or perhaps not even among, the parameters his proposal was addressing.

[busymom]

8. So a popularity contest then?

The 'hard' biology teacher that makes her students really pony up for the grades (angering students and parents who want their kids to get straight A's for not so much work) will be judged less positively? What about the quirky, kind of weird chemistry teacher who isn't really popular but is a good teacher...you remember the one...dressed like revenge of the nerds and everyone laughed about him behind his back....Ding there too, I guess. Of course, there was my 9th grade geometry teacher who weighed ~350 pounds and always had a beed of saliva that would stretch between his lower and upper lips (it used to mesmerize me when I was bored)...he was probably the best math teacher I ever had, but boy was HE heckled.

Merit for teachers judged by peers, parents and students as performing well?

That's nuts.


And fwiw, there are plenty of doctors that people think are real assholes because of their bedside manner that are some of the sharpest knives in the drawer...who you want on your side if you are sick...and there are some really popular, nice, christian, wholesome docs that everyone loves...but they are surgeons with the absolute highest infection rates in the hospital, etc.

We need to think about that a little harder!

[roguevalley]

19. its subjective, this review of who deserves pay. too bad people

just don't pay a good wage all around and get it over with. paying some for being popular is no indication that they are good.

[liberalhistorian]

2. As the daughter of teachers, who saw

what they endured EVERY single day for decades, I know there is no comparison between physicians and teachers. All these people weighing in on the matter need to spend a week in a classroom so that they know what the hell they're talking about. And too many doctors nowadays refuse to even see patients unless they have insurance or money upfront, no matter what the problem is. Been there, done that. I don't doubt that there are many like you're describing, but they are, frankly, in the minority. I don't see too many doctors working to get some kind of universal coverage.

And let's be honest about something. Doctors have far more leeway over who they see as patients, generally speaking. Patients, for the most part, come to them voluntarily. They may not want to be there (who the hell DOES like being sick and/or in pain, except for those with Munchousen's, etc.), but they know the doctor will likely be able to help and they generally don't give much of an attitude. Teachers have to accept ALL students, period, no matter what, no matter what their abilities, disabilities, attitude, home life, if they've even had something to eat that day, etc., etc. They spend far too much of their day having to keep order in their classes from those who do NOT want to be there and who couldn't care less. Then they have those with horrible family lives, who are abused or neglected or starved, or whose parents just don't give a shit. Then they have to deal with being blamed for everything and with administrators who are too scared of parents to stand up for the teachers, even when they know the teachers are right and the parents are wrong. Teachers can't stand over kids at night and force them to do their homework. If a kid doesn't do his homework and goofs off in class, to far too many parents, that's the teacher's fault. EVERYTHING is the teacher's fault because their little darlings would never do anything wrong. And an administrator who gets paid twice as much as the teacher for half as much work gets on the teacher's case for something over which they have no control.

And frankly, given that I just buried my lifelong best friend who died SOLELY due to gross negligence on the part of the doctor and the hospital, and after a year of constant hospitalization and suffering, negligence that was inexcusable and shown clearly by the medical records, and having seen too many people lately get turned away by doctors simply because they don't have insurance or enough money, I'm not too charitably inclined towards the medical profession these days.

And people wonder why no one is going into teaching anymore. It was certainly a no-brainer for me, I wanted nothing to do with it after twenty years of watching the shit my parents dealt with daily for very little compensation or respect/appreciation. Doctors earn more than teachers? Gee, ya fucking THINK???? Sheesh. I just love all these people who've never set foot in a classroom except as a student who think they know everything about education and teaching. THEY DON'T.

[busymom]

6. seriously...

I would argue that most of the people here don't know what they're talking about. I'm not arguing against teachers...someone in that thread asked for an example with docs and I gave it.

Have you followed a doctor around for a week to see what they do? They're not all just sitting in the lounge talking about their Beamers.

No one likes being sick (and many docs don't have the choice about patients that they see, btw) ...but let's be honest here. Would you call a plumber out to your house if your toilet got backed up, there was no place to take a...dump, but you had no money and didn't intend to pay? Doctors don't take patients with certain insurance policies anymore because they don't get paid by them. Most doctors that I know though have a certain number of patients that they see pro bono or for a very small fee...they just can't fill their practice entirely with them. It's a HUGE issue with medicare (which I see brought up here again and again as the panacea of health care). Doctors leave medical school with ~150,000 dollars in debt. That's a big chunk of change. They then serve as residents from 3-10 years depending on their specialty and whether or not they do research and they work 100+ hours a week even with the bogus new 80 hour work week requirements.

There is no choice about this. If you want to become a doctor, you have to do this...family, children, life be damned. During my husband's training years we didn't have good health insurance at all AND had no dental insurance....and he was WORKING for the hospital as a DOCTOR. We did not qualify for any aid for our children even though our income was negligible. He worked so many long hours that it became impossible for me to work with his erratic hours. It was terrible.

We finished training and were hit with taxes. After taxes and paying off loan debt, we were no better off financially than during residency and fellowship. We lived paycheck to paycheck, had garage sale furniture in our very modest home AND just to be clear...for the entire time of training and raising 3 children...and for his first THREE years of working as a "real" doctor...we had only ONE vehicle.

I drove him to work every day and picked him up...with all of the kids.

Is this the glamorous doctor life you envisioned?

We are 8 years out of training and are finally getting our heads above water in regards to the mountains of debt that my husband accumulated. Do we live in a nicer home now? Yes. Do we live an extravagant lifestyle? no. We pay a shitload in taxes (and will never see anything for our children or ourselves for that money...which is fine if it isn't going to fund the Iraq war) but on top of it, we get to listen now to the resentment of people around us .... how dare we be more comfortable now financially...he should be working for free or for peanuts I guess.

It's as if people really believe what they see on ER.

And by the way...I have taught for years....in a classroom...with students...

I am very grateful for the hard work teachers do....and I understand it at a personal level.

At the same time, I am also very grateful for the hard work that doctors do and the hard road to get there...

The next time you visit a doctor, it might help to imagine the sacrifices that that person made in his personal and family life to get there. My best friend's husband is a pediatric surgeon who has spent more time with other people's children than his own...he falls terribly short as a husband and father, but he is one of the best damned peds surgeons you could ask for. If your child was sick, you would be asking for him to operate.

The cost of becoming that good is doing a LOT of surgeries...in a short period of time...again and again and again over a few years to refine your technique until you are let loose on the public without supervision and then are actually paid for your work like a "real doctor".

The cost...is family, friends, personal life and sometimes personal health...but we all want our doctors to be the best. Many things in medicine are learned through experience and repetition and you can only get that with multiple patient contacts...do it, repeat it, do it again...until you master it...

There is sacrifice involved, and it has to be compensated...if it isn't...people won't make those sacrifices anymore.

There will need to be a complete overhaul of the medical training system to achieve what many people here are talking about. No one is going to take on ~150,000 + in debt, work like a slave for 100 hours/week and endure the challenges of working with sick people (and we all know we're needy when we're sick...at least I am) to not earn enough money to have some nice extras in their lives or at least be able to pay off their student loans.

[trayfoot]

18. This particular statement grabbed me...........

busymom said:

There is sacrifice involved, and it has to be compensated...if it isn't...people won't make those sacrifices anymore.

************************

As an educator, I understand this sentiment. It applies to the teaching profession, as well. When I was steered toward the teaching profession, teachers weren't paid much, but there were other perks for their hard work and long hours ---- RESPECT, APPRECIATION. As decades passed, these wonderful perks dried up and I was working in an environment where my talents, education, expertise were discounted - and in their place, there was a feeling that I should be "grateful" to have a job, that parents looked at me as their child care provider (babysitter). My bosses were no longer concerned with "instruction" - just don't "make waves" or "upset parents". Don't have too high a standard. There was ALWAYS an excuse as to why teachers couldn't get a living wage. We were expected to be altruistic to the hilt, and we were. I averaged spending more than a thousand dollars a year on my students - this on a teacher's pay. As I had student teachers come in and scoff at my requirements for them to do the same level of work that I did to prepare for classes and take care of the myriad of other chores teachers have to complete, it became clear to me that without MAJOR changes across the board, the system would NOT be replacing us old workhorses with the best and the brightest. Those changes include bringing back the RESPECT and APPRECIATION for teachers, and education in general. It means that teachers (ALL) be rewarded sizable pay increases, so that during the summer when they are off they don't qualify for food stamps, as many of ours do. It means that disruptive children be MANAGED and taken out of the classroom so others can learn. That involves changing the mindset of bosses and school boards who just don't want "any problems". I could go on and on, but the bottom line is: Until this nation begins to embrace and TOTALLY support education and intellectualism again, there will be no improvements. Merit pay will not solve what is wrong with public education - it will only make the politicians THINK they have done something.

[Bread and Circus]

3. I was thinking about this as I am a physician and here are my thoughts and possible solutions:

The problem with "merit based" pay for physicians is that the way they are measuring merit is all wrong. On the hand of the insurance companies, what they are really measuring is not merit but how much money you save them. They have a variety of means to do this, disguised as quality care, but it really boils down to dollars save for them and their shareholders No big surprise there. On the other hand, the government wants to get into this game and they are piloting this w/ performance pay for clinical outcomes. As the OP pointed, a lot patient oriented clinical outcomes depend on the patient themselves, especially when it comes to lifestyle diseases or diseases heavily influenced by lifestyle (hypertension, dyslipidemia, diabetes mellitus type 2). I think that system is pretty doomed to failure and gamesmanship and outright manipulation by who you let in your practice, what side of town you are on, and what party of the country you live in.

But all hope is not lost in my opinion.

Generally, performance in medicine follows attitude, training, knowledge, and skills.

What I would like to see is more emphasis on ongoing medical education and TESTING for physicians and gear the fee for service scale to be more proportional to the classes the physicians take as well as how they do on multi-faceted testing parameters.

This will serve to improve the quality of each individual physician because they will push themselves harder to improve their fund of knowledge, gain more insight in the humanist aspect of care, and improve their procedural skill set.

So, as a physician, I agree with merit based pay but I think it should correlate with the amount of ongoing training and testing scores. Reward the physician on his or her effort and merit.

Just looking at a1c scores and a few other indices would be a very narrow measure of the quality of care. But, even with that said, I'd be happy to accept some pay for performance scheme if it was fair and accurate. Can insurance companies make fair and accurate systems based on patient outcomes? Maybe. However they will have to take into account a lot of other factors. It's one thing to be delivering care to a wealthy and highly educated suburb. It's another to be slogging it out in the back woods of Appalachia or the deep South.

A large portion of the health care dollar is because of cigarettes, unhealthy diet (partly promoted by big Agriculture), and an obscene amount of lack of activity. These 3 factors contribute extensively to:

Heart disease
Stroke
Cancer
Diabetes
Dyslipidemia
Hypertension
Blindness
Kidney Failure
Emphysema

which are also known as the things that generally kill Americans and cost us so damn much.

So, which part of the chain of bad lifestyle to bad disease to bad clinic outcomes would yield the best bang for the buck?

At the industrial level?
At the physician level managing his patients as a "population" of outcomes?
At the individual level?

OR all 3?

And how do you actually quantify each party's contribution to the bottom line?

Like I said before, I'm open to pay for performance for physicians. I don't fully embrace the "measured outcomes" approach because a.) such a system will hard to design to measure all the things that go into good care and b.) such a system will be gamed. I'd be willing to try such a system.

I think a better system would be to amp up opportunity and requirements for more ongoing physician education and TESTING so that physicians would be stratified within their specialties and their fee-for-service payment scheduled would be adjusted accordingly. What you would see is that overall doctors, in an effort to compete with each other, would improve their current knowledge of diagnosis, treatment, and procedures. This improved knowledge would translate NATURALLY into better care and safer practices. Also, you would see really marginal doctors likely fall behind, and this might in effect weed out some folks that shouldn't be doctors at all.

Well, that's my 2 cents.

[ProSense]

4. How does malpractice fit into that logic? n/t

[KT2000]

5. Well - this is sickening

Isn't it possible for doctors in this country to come together and stand up to this bullying?
You all know that non-medical people are making the decisions that guide compensation for medical care. Why is there not outrage from the entire profession and a statement of ethical guidelines that doctors will not cross. There is a lot of power in the medical community.

I once got hold of a Blue Cross Blue Shield text book that was used for instructing people in the insurance companies about the transition in medical care to managed care.
Most references to physicians had to do with recognizing aspects of their "ego" and various strategies to circumvent obstructions the "egos" may cause. The physician was regarded a someone to be manipulated to accept the changes.

I am sorry but physicians need to lead the charge on cleaning up health care for the sake of health - not insurance company profits. The patients can't do it. As it is now, patients who are not compliant to the system you have described are a pain to the doctors.

[busymom]

7. Physicians are busy

taking care of patients...and unforunately, the big guns organizations like the AMA are more political in other ways that aren't useful to most docs and patients.

The truth is that many doctors talk about these issues and are angry about them...but they are so busy in their practices caring for their patients that they don't have time for political activism at the level it would require.

[LuckyLib]

15. They need to do what the Airline Pilots Association does -- identify very savvy, very good

communicators who know the business and can speak to congress and the public about issues of interest to both airline employees and the flying public. They are paid what they would be getting if they were "on line" and can direct their energy to keeping travel safe.

Doctors have knuckled under for far too long to the medical insurance industry. Only in the last 5 years have the protests increased from their corner, as insurance companies gouge both doctors and patients.

[busymom]

16. Doctors in America don't unionize though...

I know that there are moral reasons for doing that, but I don't know the legal end of it.

Can you IMAGINE your doctor going on strike because they aren't getting paid by insurance companies? People would spit at them in the streets. Besides that, I don't know a single doctor who would be willing to go on strike and abandon their patients.

Instead, Doctors simply have started telling patients "I'm sorry, but we can't accept your insurance because it doesn't pay/pays 6 months later" and then they let the consumer go back to the insurance companies to complain.

Doctors can't use the same tools as the airlines. My dad flew for American Airlines...and when they didn't get what they wanted, they went on strike. Somehow, shutting down an airline and shutting down a hospital/practice with sick and dying patients doesn't feel the same to me.

[Hekate]

9. KnR. Thanks for starting this thread, busymom. I hope it goes well...

... and doesn't attract the snarks.

Teachers and doctors may have different pay scales, but they are both difficult professions. Thanks to both of you for persevering. :hug:

Hekate

[WinkyDink]

10. I'm not getting your point. I and my husband are retired teachers; my B-i-L is a world-known doctor.

I have the UTMOST respect and gratitude for American physicians, and begrudge them not one dime.

But public schools and kids just ain't the same bailiwick.

[busymom]

11. This thread was started by request.

There was a thread with the same name about teachers and it was requested by some of the posters that similar threads be started about other professional groups and doctors were one of them. It is the only reason that I started the thread and gave it the same title...This is a break-away from that thread as requested. It is not meant to compare doctors to teachers.

[WinkyDink]

17. Okey-doke!

[busymom]

12. LOL

Clearly doctors just aren't a popular group.

You guys might need to turn off Grey's anatomy and ER...Life in the real world of a doctor is the opposite of what a lot of people here tend to think.

[HamdenRice]

13. Problem with your argument: You're comparing teaching to the most fucked up system in the US

It's impossible to compare the way doctors are treated to any other profession, because the medical system is the most broken, fucked up, irrational, useless, destructive, degrading and pointless in the country.

It would be as though we were talking about, say, the condition of iron workers in New England in 1860 and you started talking about how slaves are treated in Alabama as a comparison.

How doctors are treated under the rule of insurance companies teaches us nothing about anything -- except how to construct and operate the most fucked up of all possible systems.

[busymom]

14. Again...this was in response to a request

in the thread with the same title about teachers...it was an attempt to discuss some of the things that are broken and the merit pay system for doctors. I'm not sure that I even understand your analogies in that regard.

The topic has been merit pay and how it affects different professional groups...starting with teachers. Someone piped up and asked the question about merit pay for doctors and other professional groups, so I decided to start that discussion.

It is just as valid as the discussion about teachers and I think it is a great parallel to how the tools to design merit-based pay are totally screwed up...across the board. It's another reason to rethink how we judge professionals.

[windoe]

20. Everyone is an expert in their own area

and I believe improvement in medicine, education and law must come from within as well as outside. Corruption has come from outside each of these systems and professions have suffered from a loss of their collective voices in how they wish to do their jobs and uphold their very ethics. Universities are funded by the very corporations that end up controlling these professions, so the seeds of compliance are planted early.

Workers voices have to balance the equation with outside oversight. Both are necessary for this system of checks and balances to function. Without a collective voice, working conditions and professional ethics deteriorate, and this has happened across the board in this country.

So I am sorry to say this, but there is no excuse for doctors to say they do not have time to defend the patients they serve. Their ethics demands they speak out collectively to demand better hospital conditions to match the corporate powers who care not for peoples lives. They must have independent representation, sign petitions, and get organized.

Unfortunately once again workers have to struggle again to regain their rights, right to a fair salary, job security and working conditions, and the right to perform their job in an ethical manner without outside interference. We have all lost so much.