Mrs Buttocks: “Dr, my husband (indicates to patient) has a bad family history. His brother and his bad both went bald early and had heart attacks. My husband is already bald so I am worried he also might be a risk to having a heart attack”
Mr Dickus (visibly annoyed): “Yeah, well at least I also inherited my Dad’s big penis. Is hair more important to you? No. I thought so.”
I read with interest about a lawsuit going on now in Florida. An ER doc there is suing her employers (Emergency Resources Group and Baptist Medical Center) over the way they docs are paid. Like the vast majority of jobs, there is an incentive/productivity bonus built in. Basically it means a bonus is given based on how efficient you are. At this particular place, the bonus is based on how you move the meat, ie the number of patients you see per hour. As per the suit, you need to see at least 2.0 pts per hour to get the best bonus, less than that you get less or eventually, nothing extra. Since this doc saw less than 1.5 pts her hour, she got ziltch. Eventually she was more or less written off the schedule.
She alleges in the suit that this incentive not only makes you just rush your work but contributes to a dangerous situation where patients are sent home inappropriately (one patient was septic and was discharged) in order to maintain one’s speed. She’s not suing for very much money but is doing it more to make a point.
I agree on one point here. Incentives based entirely on pts per hour is unethical and contributes to some terrible practices. First, it does make you blast through your work and do slipshod workups – either admitting people or discharging them too quickly without enough thought or until tests come back. Second, it can cause “cherry picking” whereby MD’s preferentially pick up patients with simple, straightforward problems. They will avoid psych pts, pts needing big workups, chronic pain patients, etc or anyone that will slow them down. More or less you want to just be in fast track. Obviously this creates animosity between the docs (and PA’s/NP’s).
However, I do agree that without some incentive, many docs will just be totally lazy and see 1 patient her hour or less! Some docs are just big-workup-ers who can’t dispo people to begin with and this will just validate their behavior. Why bother being faster if you get the same money?! This doc here is probably seriously slow (and I bet a nightmare to work with). She needs a kick in the ass of some kind to get closer to 2 per hours. The incentive that is more fair is RVU based – ie how many RVU’s you BILL for (you can’t base it on collections since then you won’t want to see any Medicaid or self pay patients). It can be RVU’s per patient per hour or something like that. That means that if you get some really sick patients that slow you down, at least you are billing a lot of critical care time and procedures which will boost your RVU numbers over a bunch of ankle sprains.
The reality is if you don’t want the pressure of seeing patients faster and more efficiently (ie not ordering millions of unnecessary blood and imaging tests), you need to work in an academic job where you are just flat salaried. If you work in any other institution, you can’t be a slug or else you’ll miss out on the money. That’s the way it should be Dr White. However, I agree that just pts per hour as the method of incentivizing one’s pay is wrong. Make it RVU based.
WhiteCoat back with this week’s healthcare update. More medical news from around the web at my blog on EP Monthly.
Medicare audits pushing hospitals to stick it to patient/“beneficiaries.” RAC audits are pushing hospitals to classify patients as “observation” status rather than risk being sued and fined for inappropriately classifying admitted patient as “inpatient.” Yet that “observation” status will likely stick the elderly patients with a large bill for the medical services. One example: Patients transferred to a nursing home who were classified as “observation” status during their hospital stay have to pay for the nursing home themselves. If patients were “admitted” for three days, then Medicare picks up the tab.
Florida’s Lee Memorial Health System is now “asking” emergency department physicians not to prescribe narcotic pain medications to patients. In other words, prescribe them too much in our hospital and you’ll be looking for another job.
Lack of psychiatric beds causes overcrowding in UCLA Medical Center to the point that some admitted patients must sleep on mattresses on the floor.
Washington State no longer paying for “unnecessary” ED visits by Medicaid patients.
At the same time, emergency physicians in Canada are refusing to treat nonemergency patients in the emergency department.
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