Rethinking How Doctors Get Paid

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House calls were once a hallmark of medical civilization

Doctors make a lot of money. Most people accept this as being probably OK, given all the time we spend saving lives and eradicating disease. I do bear a little grousing now and then when some life that I’ve saved doesn’t much resemble the condition it was in before I went to work, or when a nasty disease I had wiped out is reincarnated just as I’m congratulating someone on his or her cure. Yes, at times like these the grapes can get pretty sour.

Take the case of Howard Grimstone, my auto mechanic. Grimstone came to see me because he got a twinge in his chest after chopping four cords of wood. By the time I saw him, he felt pretty good. “Don’t think it’s much, Doc,” he said. “But I just thought I’d have you check it out.”

I wasn’t fooled for a second. Quicker than you can shake a stick, I had him up to the medical center for one of those bypass operations. They fixed his coronary slick as a whistle. I was quite pleased with my prompt action. Grimstone was less impressed. During surgery he had a stroke, and now he can’t use his right arm. “Helluva way to get a guy to stop chopping wood,” said Grimstone. “I coulda cut the thing off myself and saved 50 grand.”

As if that weren’t enough of a blow to my sensibilities, Grimstone added insult to injury. “Suppose you came to me because your car wouldn’t start. Then when you got it back, the car started fine, but ran only in reverse. How much do you think I’d charge?”

Grimstone had a point, but if I had to guarantee my work, I’d be out of business in a flash. Asking a doctor to stand behind his treatment is like asking a politician to live up to his campaign promises. It just isn’t done. (And nobody expects it, either. When I first started my medical practice, I offered my patients a one-week guarantee on my work, parts and labor included. One week may not sound like much, but for the patient clever enough to see me every week, it could mean immortality. In theory anyway. Nobody was interested.)

It’s not our fault–it has to do with how doctors get paid. We do what we do because the people who pay us tell us to do it that way. Insurance companies, that is. Insurance companies don’t pay us for saving lives or making people feel better. They pay us for doing things. Some things they pay more for than others. Some people at Harvard looked at how we get paid. They concluded that a doctor who does an operation or some kind of procedure makes about eight times as much as a doctor who just sits around and talks, and that a doctor who puts you to sleep makes the most of all. They figured a doctor who kept patients healthy would go broke. It doesn’t take a degree from Harvard to figure out why we operate first and ask questions later.

When folks in the government saw the results of this survey, they decided that something was wrong with this kind of system. (Some of these government folks, by the way, have nothing better to do than to complain that we perform unnecessary operations, order unnecessary tests and prescribe unnecessary treatments; people who, when it comes to unnecessariness, live in glass houses.) Now they are proposing to change insurance so that doctors will get paid more for talking and listening, and less for sticking and poking. Their reasoning is that this will reduce a lot of unnecessary procedures and lead to better doctor-patient relationships.

It sure will. Doctors are like everybody else. We like to do a good job, but we’re not going to cut off your nose to spite our face. Pay us to talk, and we’ll be calling you on the phone or dropping in for supper asking about the family, and how’d you like to know about cholesterol, and what’d you think of those Red Sox. Doctors will become regular, sociable folk.

If you’ve got chest pain or rectal bleeding, we’ll tell you all about risks and benefits, and considerations and complications, and even sympathize with you a bit. We won’t waste time patching up coronaries or looking up colons. We’ll sit around and chew the fat . The new system should work fine. Except for one detail: Some things that doctors do happen to be useful, and we should be encouraged to keep doing them, only not quite so much. In this respect, doctors are a lot like farmers.

The government doesn’t want farmers to raise too much wheat or too many pigs, but it doesn’t want them to get discouraged and turn to real estate either, because farmers are important people to have around.

The government has figured out how to keep farmers working at just the right pace. It invented something called subsidies. Washington should do the same for us. Give the heart surgeon 12% of his income if he reduces his case load by 10%. Pay the gastroenterologist $600 for the first 50 colonoscopies she doesn’t do. And for the general practitioner who dispenses one less drug per patient–a month’s vacation in Hawaii.

With a little fine-tuning the government could get doctors to do whatever it wanted them to do–and nothing else.