Comments on: Should health care come with a warranty? http://www.kevinmd.com/blog/2009/07/should-health-care-come-with-a-warranty.html Wed, 15 Feb 2012 00:27:00 +0000 hourly 1 By: Matthttp://www.kevinmd.com/blog/2009/07/should-health-care-come-with-a-warranty.html#comment-108510 Matt Mon, 27 Jul 2009 00:13:43 +0000 http://www.kevinmd.com/blog/?p=39303#comment-108510 "So you don’t believe unnecessary tests and referrals are ordered for defensive medicine purposes?"Maybe they are and maybe they aren't. If we could agree on what that term meant, even then there are probably lots of reasons, Kevin's even highlighted others here.What I said was that the "reform" physicians have been proposing will save us all this money, get rural areas all these docs, etc. has never been shown to work that way, despite 30 years of it. And I also said that you say referrals are made because of physicians covering their butts, but they have no idea if that actually works to cover their butts. So I wonder why they do it?If physicians want to be only judged by other physicians, that's fine with me as long as every industry gets that when they're a defendant. So when physicians file class actions against health insurers for failure to reimburse, the health insurers get a jury of adjusters.You want the British system? Give us nationalized healthcare and you'll get it, I bet. Although the tradeoff is a poor one.The best way to reduce your exposure would be to revamp your reimbursement plan to compensate you for time with the patient. Study after study have shown that better communication = fewer claims.You wonder why "tort reform" isn't being discussed? Because it's not that much of a cost driver when you look at the truly quantifiable numbers. You say "well, defensive medicine costs a lot", but physicians can't really agree on what is and is not defensive medicine, and no "reform" we've tried yet has ever been shown to reduce it. “So you don’t believe unnecessary tests and referrals are ordered for defensive medicine purposes?”

Maybe they are and maybe they aren’t. If we could agree on what that term meant, even then there are probably lots of reasons, Kevin’s even highlighted others here.

What I said was that the “reform” physicians have been proposing will save us all this money, get rural areas all these docs, etc. has never been shown to work that way, despite 30 years of it. And I also said that you say referrals are made because of physicians covering their butts, but they have no idea if that actually works to cover their butts. So I wonder why they do it?

If physicians want to be only judged by other physicians, that’s fine with me as long as every industry gets that when they’re a defendant. So when physicians file class actions against health insurers for failure to reimburse, the health insurers get a jury of adjusters.

You want the British system? Give us nationalized healthcare and you’ll get it, I bet. Although the tradeoff is a poor one.

The best way to reduce your exposure would be to revamp your reimbursement plan to compensate you for time with the patient. Study after study have shown that better communication = fewer claims.

You wonder why “tort reform” isn’t being discussed? Because it’s not that much of a cost driver when you look at the truly quantifiable numbers. You say “well, defensive medicine costs a lot”, but physicians can’t really agree on what is and is not defensive medicine, and no “reform” we’ve tried yet has ever been shown to reduce it.

]]> By: Skeptical Dochttp://www.kevinmd.com/blog/2009/07/should-health-care-come-with-a-warranty.html#comment-108503 Skeptical Doc Sun, 26 Jul 2009 18:35:00 +0000 http://www.kevinmd.com/blog/?p=39303#comment-108503 To Matt, So you don't believe unnecessary tests and referrals are ordered for defensive medicine purposes? I know in some states limits have been placed on pain and suffering rewards, but (tell me I'm wrong) the overall malpractice system hasn't really been altered. Specifically, tort reform where accused physicians are judged by a true jury of their peers and a select group of other experts? Or maybe the British system, where doctors found innocent don't have to pay the legal fees the suit caused them. In our current system, even if you're innocent you're still penalized. So I stand by my statement that the current malpractice legal structure needs revamping, then we can really see if it makes a difference in physicians' actions and unnecessary tests, referrals and costs. To Matt,
So you don’t believe unnecessary tests and referrals are ordered for defensive medicine purposes? I know in some states limits have been placed on pain and suffering rewards, but (tell me I’m wrong) the overall malpractice system hasn’t really been altered. Specifically, tort reform where accused physicians are judged by a true jury of their peers and a select group of other experts? Or maybe the British system, where doctors found innocent don’t have to pay the legal fees the suit caused them. In our current system, even if you’re innocent you’re still penalized. So I stand by my statement that the current malpractice legal structure needs revamping, then we can really see if it makes a difference in physicians’ actions and unnecessary tests, referrals and costs.

]]> By: Skeptical Dochttp://www.kevinmd.com/blog/2009/07/should-health-care-come-with-a-warranty.html#comment-108501 Skeptical Doc Sun, 26 Jul 2009 18:20:47 +0000 http://www.kevinmd.com/blog/?p=39303#comment-108501 HH, Regarding my previous statement, and your reply: I don't disagree with you. I'm just stating what I think happens because of defensive medicine. In fact, I thought I was stating the obvious- what happens "out there" in the trenches. Many many referrals to specialists aren't made because the primary care doc doesn't know how to manage the condition, they either don't have the time to properly manage a time-consuming condition, or covering their butt in case of lawsuits. OH how I wish it weren't so. I just don't understand (except from a political donations standpoint) why Tort reform isn't being discussed as part of the new healthcare system being created... HH,
Regarding my previous statement, and your reply:
I don’t disagree with you. I’m just stating what I think happens because of defensive medicine. In fact, I thought I was stating the obvious- what happens “out there” in the trenches. Many many referrals to specialists aren’t made because the primary care doc doesn’t know how to manage the condition, they either don’t have the time to properly manage a time-consuming condition, or covering their butt in case of lawsuits. OH how I wish it weren’t so. I just don’t understand (except from a political donations standpoint) why Tort reform isn’t being discussed as part of the new healthcare system being created…

]]> By: Matthttp://www.kevinmd.com/blog/2009/07/should-health-care-come-with-a-warranty.html#comment-108497 Matt Sun, 26 Jul 2009 14:13:59 +0000 http://www.kevinmd.com/blog/?p=39303#comment-108497 Tort reform has been in existence in some states for three decades now. Has it changed physicians actions? There is almost no evidence it has in those states. Perhaps it's time to look for new ideas rather than recycling old ones we know don't work. Tort reform has been in existence in some states for three decades now. Has it changed physicians actions? There is almost no evidence it has in those states. Perhaps it’s time to look for new ideas rather than recycling old ones we know don’t work.

]]> By: Happy Hospitalisthttp://www.kevinmd.com/blog/2009/07/should-health-care-come-with-a-warranty.html#comment-108496 Happy Hospitalist Sun, 26 Jul 2009 14:06:53 +0000 http://www.kevinmd.com/blog/?p=39303#comment-108496 Skeptical doc, by that reasoning, every sore throat should be referred to an ENT because they may have an abscess hiding down there.That's medicine based on fear. It establishes irrational standards. Referring all Afib because you might get sued is a horrible way to practice medicine. That's part of the problem Skeptical doc, by that reasoning, every sore throat should be referred to an ENT because they may have an abscess hiding down there.

That’s medicine based on fear. It establishes irrational standards. Referring all Afib because you might get sued is a horrible way to practice medicine. That’s part of the problem

]]> By: Skeptical Dochttp://www.kevinmd.com/blog/2009/07/should-health-care-come-with-a-warranty.html#comment-108485 Skeptical Doc Sun, 26 Jul 2009 03:30:39 +0000 http://www.kevinmd.com/blog/?p=39303#comment-108485 To Ray: I admire the smart hospitalist who wants to manage A. Fib without a cardiologist's help. That would be more efficient. He'll do that 100 times without a problem, and then 1 patient will have a bad outcome and he'll get sued. After the suit is filed, he'll ask for a cardiologist consult on every other AF patient he treats, whether he could handle the next 100 AF patients or not. If he loses the lawsuit because the lawyer asked him why he didn't call a cardiologist, every dime he saved the system for the first 100 patients will be awarded to the family of the patient who died. But then again, that reward money doesn't come from the taxpayer so maybe it's a good strategy. My point is, tort reform with limits to prevent egregious rewards needs to happen or the doctors are going to be at a bigger disadvantage than they are now. To Ray: I admire the smart hospitalist who wants to manage A. Fib without a cardiologist’s help. That would be more efficient. He’ll do that 100 times without a problem, and then 1 patient will have a bad outcome and he’ll get sued. After the suit is filed, he’ll ask for a cardiologist consult on every other AF patient he treats, whether he could handle the next 100 AF patients or not. If he loses the lawsuit because the lawyer asked him why he didn’t call a cardiologist, every dime he saved the system for the first 100 patients will be awarded to the family of the patient who died. But then again, that reward money doesn’t come from the taxpayer so maybe it’s a good strategy. My point is, tort reform with limits to prevent egregious rewards needs to happen or the doctors are going to be at a bigger disadvantage than they are now.

]]> By: Doc99http://www.kevinmd.com/blog/2009/07/should-health-care-come-with-a-warranty.html#comment-108476 Doc99 Sat, 25 Jul 2009 15:55:22 +0000 http://www.kevinmd.com/blog/?p=39303#comment-108476 "Don't patients have any skin in this game?"No ... not since the days of third party payors, they don't. And under the Public Option Obamacare, only the Government will own the game. “Don’t patients have any skin in this game?”

No … not since the days of third party payors, they don’t. And under the Public Option Obamacare, only the Government will own the game.

]]> By: Happy Hospitalisthttp://www.kevinmd.com/blog/2009/07/should-health-care-come-with-a-warranty.html#comment-108470 Happy Hospitalist Sat, 25 Jul 2009 13:12:03 +0000 http://www.kevinmd.com/blog/?p=39303#comment-108470 alex, the consult is billed separately. As for cutting the payment every year, that is a result of the economics of RVU, not bundled care. RVU economics dictates how much you get in our fee for service system. It's not the bundling that's the problem. Bundling drives efficiency. I've never seen a surgeon waste time writing full page post op notes, because they don't need to to get paid.Would you rather have the government dictate how you practice medicine or would you rather have yourself decide how to practice. I can guarantee you if you are currently practicing good medicine, you would make a windfall from bundled care models. If you are practicing wasteful medicine, you will want to retire. alex, the consult is billed separately. As for cutting the payment every year, that is a result of the economics of RVU, not bundled care. RVU economics dictates how much you get in our fee for service system. It’s not the bundling that’s the problem. Bundling drives efficiency. I’ve never seen a surgeon waste time writing full page post op notes, because they don’t need to to get paid.

Would you rather have the government dictate how you practice medicine or would you rather have yourself decide how to practice. I can guarantee you if you are currently practicing good medicine, you would make a windfall from bundled care models. If you are practicing wasteful medicine, you will want to retire.

]]> By: Okulushttp://www.kevinmd.com/blog/2009/07/should-health-care-come-with-a-warranty.html#comment-108464 Okulus Sat, 25 Jul 2009 10:26:51 +0000 http://www.kevinmd.com/blog/?p=39303#comment-108464 For surgeons, it already exists. It is called the inclusive period, which for an increasing number of procedures includes all care (regardless of how you code modifiers) for up to 90 days following surgery, both inpatient, outpatient, procedural and cognitive.And you don't get paid any extra for it.So now you are wanting to bundle cognitive work alone. And will this plan also include a single payment to be divided amongst all involved providers for a period of time? If so, who will make the determination of how the fixed sum is divided? Will there be rewards and penalties? (Suppose on an admission for CHF exacerbation, will the hospitalist be penalized his payment when he consults a cardiologist or nephrologist than when he does not?--then it would seem to work like capitated plans in at least one way.) I am not sure the incentive is all that desirable, or really all that much in favor of the patient, at least potentially so. What if the patient wants services that the physician deems unnecessary? Do patients have any skin in the game? For surgeons, it already exists. It is called the inclusive period, which for an increasing number of procedures includes all care (regardless of how you code modifiers) for up to 90 days following surgery, both inpatient, outpatient, procedural and cognitive.

And you don’t get paid any extra for it.

So now you are wanting to bundle cognitive work alone. And will this plan also include a single payment to be divided amongst all involved providers for a period of time? If so, who will make the determination of how the fixed sum is divided? Will there be rewards and penalties? (Suppose on an admission for CHF exacerbation, will the hospitalist be penalized his payment when he consults a cardiologist or nephrologist than when he does not?–then it would seem to work like capitated plans in at least one way.) I am not sure the incentive is all that desirable, or really all that much in favor of the patient, at least potentially so. What if the patient wants services that the physician deems unnecessary? Do patients have any skin in the game?

]]> By: Rayhttp://www.kevinmd.com/blog/2009/07/should-health-care-come-with-a-warranty.html#comment-108458 Ray Sat, 25 Jul 2009 06:10:39 +0000 http://www.kevinmd.com/blog/?p=39303#comment-108458 Suppose a smart hospitalist handles chest pain and Atrial fibrillation without unecessary cardiology consult and avoids overtesting with various CT, mutiple imaging etc, he should be rewarded as opposed to someone who call 2- 3 consults and orders multiple imaging. I still can not believe we can get away with this nonsense in our system. Bundled payment system where the smart and efficient get significant payments because they handled most care should be instituted. Shameful that doctors don't talk enough about efficent care and value payments. They're opposing reform while not proposing how to attain the best care. Doctors need to lead rather than oppose or just follow. Why can not their own societies come up with reasonable suggestions and why can not they help identify great ones amongst themselves? All you hear is complaints about how they save the patient and have high loans. They are acting silly in this intense debate. Suppose a smart hospitalist handles chest pain and Atrial fibrillation without unecessary cardiology consult and avoids overtesting with various CT, mutiple imaging etc, he should be rewarded as opposed to someone who call 2- 3 consults and orders multiple imaging. I still can not believe we can get away with this nonsense in our system. Bundled payment system where the smart and efficient get significant payments because they handled most care should be instituted. Shameful that doctors don’t talk enough about efficent care and value payments. They’re opposing reform while not proposing how to attain the best care. Doctors need to lead rather than oppose or just follow. Why can not their own societies come up with reasonable suggestions and why can not they help identify great ones amongst themselves? All you hear is complaints about how they save the patient and have high loans. They are acting silly in this intense debate.

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