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August13

Posted by:John Ellis
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doctors pay
While many are concerned about Obamacare and the Medicare SGR system, longer-term, crystal ball projections suggest either greater changes.  This has struck me through reading several disparate pieces recently.

We are paid by time.  While we have cherished this, many fields, including law and accounting are moving away from this approach.  Notes the NY Times in profiling an accountant who ended his firm’s billable hour policy in favor of embracing complex, customized work:

…He was convinced, in fact, that the billable hour was part of a series of mistakes that took all the fun out of his profession. To him, it seemed like a relic of a dying economic age and one that was depriving his industry of billions in profit….  A few years ago, he said, he realized that the billable hour was undercutting his value — it was his profession’s commodity, suggesting to clients that he and his colleagues were interchangeable containers of finite, measurable units that could be traded for money. Perhaps the biggest problem, though, was that billing by the hour incentivized long, boring projects rather than those that required specialized, valuable insight that couldn’t (and shouldn’t) be measured in time. Paradoxically, the billable hour encouraged Blumer and his colleagues to spend more time than necessary on routine work rather than on the more nuanced jobs.

Many economists have tried to break professional “knowledge workers” down into their component parts. It’s fraught enough with lawyers and accountants, Bosworth says, but it’s all but impossible with other professions, like doctors and teachers.

But then I read about attempts to do just that – measure the value added by individual clinicians. I read a series of blog posts and articles about health “hackivists,” who are merging public databases for the states and federal government to start to examine individual physician performance.  (This is also scary, because researchers have shown that “deidentified” data can indeed be linked to real people).

A profile of one health IT innovator makes references to the movie Moneyball:

Over the years, Trotter has built a reputation for advocating open-source software in healthcare and finding interesting applications for seemingly mundane datasets. But his most recent round of internet fame is the result of a successful crowdfunding project called DocGraph that used Medicare data to show how physicians team up to treat patients…

That kind of information could not only give patients a sense of which doctors are most respected by their peers, it could help hospitals understand the referral patterns associated with poor care coordination…

Much like Facebook’s social graph maps the connections between friends, Trotter’s DocGraph includes 50 million connections showing the overlapping relationships between doctors. … it provides the blueprint for a comprehensive ranking system that could give patients transparency on their doctors’ history, outcomes and assessment by peers…

Instead of taking the New York Yankees’ approach and picking the best players, “we can play ‘Moneyball’ in healthcare,” he said. “We can create big data systems that create teams of doctors where not every physician is brilliant at everything, but the team as a whole does very, very well…”

“It will take years to fully replace them, but I think it is going to be like the cowboy. That is a profession that still exists but with far fewer people doing very different things than they did before. We are reaching the end of the era of the notion that ‘doctors know best,’” he said. “I warn every doctor I know that if they want to have a job in 20 years, they had better learn to program.”

Lastly, a recent thought piece on the California Society of Anesthesiologists website lays out the value-added proposition that we bring to hospitals:

At some point in the hospital graveyard shift, the word got out – “there’s an anesthesiologist up and helping out!” That night, as I worked all through the hospital, putting in IVs, central and arterial lines, monitoring extubations and intubations, helping with sedation, altering pain orders and putting in the occasional epidural, I was left with a prevailing thought: With so much need and so many areas to share expertise, an anesthesiologist is never really unemployed in the hospital…

The next day, I thought about the economic impact of my overnight shift. In each instance, I helped patient care, but also I advanced each patient through his or her hospitalization, and in many cases probably saved a hospital day (if not a life). I made somebody some money out there, but this was largely unpaid work for me.

Should that altered-payment-model day ever come – and I believe it will –  anesthesiologists will have a giant opportunity to influence hospital care in general, and hospital length-of-stay more specifically. I also suspect, however, that we would all take a pay cut, but at least I would get paid to carry out and oversee the range of do (or better yet manage) the ABCAA  (airway, breathing, circulation, anesthesia and analgesia) hospital jaunts that I currently perform without compensation.

Your thoughts???




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