Waking Up Costs

Pay For Performance: Physicians Pay For Insurers Better Financial Performance?

Clark Venable — Fri, 28 Dec 2007 23:19:58 GMT

I've always been suspicious of the pay for performance movement. Thinking cynically (which I do more and more these days), it seemed to me that pay for performance has the backing of the insurance industry because they could use it as an excuse to pay physicians less. Show me a pay for performance program that actually increases costs to insurers and I'll show you an out-of-work actuary.

Mark Vonnegut, a pediatrician, has a perspective article in the December 27, 2007 issue of the NEJM titled Is Quality Improvement Improving Quality? A View from the Doctor's Office. I found the following a much better statement of the issue than I could ever come up with:

"I can't help suspecting that underneath all these quality-improvement and pay-for-performance initiatives lies yet another scheme that will work out very well for insurers and very badly for providers and patients."

Unfortunately, it's not free full text, but it should be (meaning you'll need a subscription to read the whole piece).

P4P: Are Vested Interests Pushing the Agenda?

Clark Venable — Fri, 30 Mar 2007 22:29:17 GMT

New Data, More Doubts About Pay-for-Performance (P4P)

"Again, as we have noted before, developing performance measures that will truly benefit patients will require detailed understanding of the clinical context, keen skeptical analysis of the available relevant research data, and careful balancing of benefits, harms and costs. All this would be very hard under the best of circumstances. But the continual attempts by those with vested ideological and financial interests to influence performance measures to advance their own interests make it unlikely that the whole P4P movement will have any good effects on patients.

The first improvement needed in the P4P movement is clear, detailed disclosure of all conflicts of interest affecting those involved in the movement at any stage.

At this point, patients and physicians should be very skeptical about who is likely to benefit from any new performance measure, particularly measures that are lavishly promoted."

This nicely sums up my suspicions about P4P beyond just the fact that it rewards task completion over the exercise of medical judgement...

[Health Care Renewal]

Medicare To Cut Physician Fees 9.9% in 2008

Clark Venable — Wed, 07 Mar 2007 16:19:29 GMT

It's official (pdf). The Center for Medicare and Medicaid plans on cutting the physician fee schedule 9.9 percent as of January 2008. Five percent for 2007 (which cut was postponed due to a temporary one year patch), and 4.9% for 2008.

DaVinci Surgical Robots. A Hospital CEO Asks Advice.

Clark Venable — Wed, 21 Feb 2007 04:00:00 GMT

Running a hospital: da Vinci Uncoded -- or, Surgical Robots Unite!

"Here you have it folks -- the problem facing every hospital, and especially every academic medical center. Do I spend over $1 million on a machine that has no proven incremental value for patients, so that our doctors can become adept at using it and stay up-to-date with the "state of the art", so that I can then spend more money marketing it, and so that I can protect profitable market share against similar moves by my competitors?"

I just discovered this blog today via Medgadget and am already impressed. The large health system our group works in purchased a DaVinci last year. I don't know outcomes yet but it was apparent to me before the purchase that it was largely driven by regional competition in Central Pennsylvania. I think it's telling that many of the institutions which were the early adopters no longer use the systems.

I'm hoping to pick one up cheap in a couple of years so I can do labor epidurals from home. ;-p

I'm 41....and free of student loan debt!

Clark Venable — Thu, 06 Apr 2006 13:27:51 GMT

I turned 41 years old today. Perhaps more significant to me, however, is that I finally paid off my last outstanding student loan! I finished medical school in 1992 and residency in 1996 so it took about ten years.

My total debt amounted to about $70,000 for college and medical school combined (without interest). Here are some interesting numbers from back then:

"Median U.S. Medical Schools Tuition and Fees for First-Year Students in 1992-3:

$20,597 for private schools
$7,544 for in-state residents at public schools
$16, 739 for out-of-state residents at public schools

Mean level of Educational debt of indebted graduates in 1992:

19.5% of medical students had no debt
$47,088 for public schools
$69,479 for private schools

And here's the data from 2003:

"Average Educational Debt

$115,218 – According to the Association of American Medical Colleges, the average educational debt of indebted graduates of the class of 2004 (including pre-med borrowing)
63% of graduates have debt of at least $100,000
81.4% of graduating medical students carry outstanding loans, combined with 62.4% with loans on college/premedical education
$91,438 – Mean per capita debt for 2003 allopathic graduates
$109,457 – Mean per capita debt for 2003 allopathic graduates excluding students without loans
$123, 800 – Mean per capita debt for 2003 osteopathic graduates, up 2.3% from the previous year
$7,277 – non-educational debt (allopathic)

One final note: If I'd stayed in academic anesthesia it would have taken at least another ten years to pay these loans off...