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Fee-For-Service (FFS) is BAD!!!

Dear Colleagues:

 

I’d like to share with you a short video by Dr. Eric Bricker posted on LinkedIn. This considers the above topic, and it is very relevant to all of us as it raises some real important questions. Dr. Bricker considers behavior in the context of culture and incentives. We should all ask ourselves about our own incentives and values. E.A. Codman would be happy that these questions are being asked; however, Dr. Bricker doesn’t really go deep enough into the root cause and solution of bad culture and incentives. As Codman’s purpose and strategy was to measure outcomes more than 100 years ago, I wanted to place Dr. Bricker’s talk in context. Please watch the video (see the link below) and I offer a few additional comments as well, so read these after you watch the video.

 

Kind Regards,

 

Jon “JP” Warner MD

Founder, CSS



Dear Dr. Bricker:

 

Don’t worry, I don’t “hate you”, though you say that 90% of doctors will after they watch this talk. I think your short video presentations are a great catalyst to make us all think about healthcare. But for those of us who are surgeons like me, we usually think in context of our own specialty. So, surgeons and internal medicine docs are different schools of fish, and to a degree the water in which we swim is our individual culture. This context is very important when talking about care deliver as it brings into play a broader consideration of models of population health vs episodes of care. I won’t get into that here.

 

I agree with you that Fee-For-Service (FFS) is problematic, and in the current healthcare world in which we live, this is an anachronism. This model encourages more services while not tying the actual outcome and quality to the payment for that service. And moving to an w-RVU model is even worse as it typically undervalues care and work provided (based on comparison to FFS models) for orthopedic surgeons like myself. Can you name another business model outside of healthcare where the quality of the service and the value provided is not tied to the payment for that service? If that is the case that business won’t survive very long. That said, Salary models also fall short on the other end of the spectrum as complexity of services (for example complex revision surgeries) are typically undervalued. (I don’t want to get into coding for complexity, but the insurance companies are problematic in valuing amount of work performed). Moreover, less care can be the game plan of some physicians as in certain hospital systems, surgeons doing a high volume of surgery are paid the same as those doing a low volume.

 

Also, before you say that Mayo, Hopkins and others with a salary structure are the best model, you should ask physicians at these institutions (in particular surgeons) how they feel about their situation and the culture in which they work. Look at the enclosed figures which give insight into the structure at many major medical centers. While it is dated it demonstrates the enormous growth of medical bureaucracy and amount of $$ spent vs that for physicians.


A.      Growth in spending in healthcare centers over time


B.      Growth in Salaries over time


Also, you really don’t mention “VALUE." While you reference William Mayo you leave out E.A Codman, the father of Value-Based Healthcare. He worked at the Mass General about 100 years ago and he demonstrated that operations the succeed are less expensive than those that fail. Yet you don’t discuss quality of care and incentives for that quality. In fact, he resigned from the Mass General in part because of his views on transparency and measurement and his disdain for colleagues who charged for their surgery without demonstrating the value they provided to their patients.

 

Finally, you talk about labels on insurance websites to identify which physicians are FFS vs Salary. You seem to be making the assumption that one model is better than the other. Not only is this not true, but it fails in one major area, quality. How about a label identifying physicians who measure outcomes and publicly report them. We need not only transparency of costs but also of outcomes, and in surgery this information is very much lacking (1). Transparency in both costs and outcomes would allow patients and insurance companies to determine where they are likely to have the best value for their care.

 

Thanks again for educating all of us and making us think about healthcare culture and accountability for care with “PATIENT FIRST” being the ultimate goal.

 

Best Regards,

 

Jon “JP” Warner MD



Reference:

 

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