Fair pay a sounder approach than "pay for quality"

A message to all physicians from the chair of the AMA Board of Trustees, William G. Plested III, MD.

By William G. Plested III, MDis a thoracic and cardiovascular surgeon from Brentwood, Calif. He served as AMA board chair during 2003-04, and as AMA president during 2006-07. Posted March 1, 2004.

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The buzzword in health care today is "quality," and everyone is getting on the bandwagon. Of course, there is no generally accepted definition of "quality medical care," so everyone adopts his or her own. For the entitlement crowd, "quality care" means free care -- the definition of free care being whatever care an individual may desire that is paid for by someone else! For insurers, "quality care" is that care that can be provided at somewhere below 80% of the premiums they have collected. For lawyers, "quality care" is that provided by physicians with unlimited medical liability insurance, provided that they tackle complex medical problems. For legislators, "quality care" means care whose true costs can be shifted to anyone else. It is only when we get to physicians that the actual well-being of patients comes into the definition of quality.

The newest scam dreamed up by the multimillionaire CEOs of health insurance companies and HMOs is to link the payment for physician services to the "quality of care" that they provide. And here again, what amazes me is how many physicians actually believe this claptrap. Every physician knows that he or she would not even consider practicing anything but the best or highest quality of medicine possible. Therefore, they feel that they certainly will receive whatever higher payment is available for "quality care." But just a minute. Do you really believe that these insurers who gleefully bludgeoned us with managed care abuses are just trying to find a way to increase the payments to all -- or at the very least, a great majority of -- physicians? I'd submit that just the opposite is true, and this is simply a way to reduce payments to the vast majority of physicians.

The "pay for quality" movement has several characteristics, the most glaring of which is that the insurers do not share the definition of quality for which they propose to pay. If their goal were truly quality, insurers would freely share their requirements for bonus payments and rejoice if all their insureds received such care and all physicians received bonus reimbursement. Clearly no one can hit an unknown target that can be changed by mere whim. But of course, that's the whole idea.

Secondly, the insurers won't tell which -- or even what percentage of -- physicians receive bonus payments. Again, this belies their professed interest in quality.

Third, only the insurers can decide who earns a "quality" bonus. There is no appeal. I can absolutely guarantee that the "pay for quality" scam will have everything to do with the perceived needs of the insurers (the need for "prestige" institutions, areas of physician shortage, compliance with insurer policies, and so forth) and precious little to do with quality care.

Finally, the whole reason for the entire exercise is to have an excuse to further underpay the vast majority of physicians for the care they routinely give -- which I must remind you is second to none in the world as far as true quality is concerned.

Unfortunately, physicians by nature, training and experience are poorly equipped to advocate appropriately for themselves in the area of compensation. We come from a long tradition of service for the good of the patient, and sacrificing monetary recompense seems not only ethical but reasonable. Demanding payment before providing care has become taboo in our society. Physicians can and should be proud that their professional ethics prevent such a reality. The ability to work without pay or work effectively in the face of significant undercompensation, however, is a time-limited proposition.

The definition of undercompensation is difficult emotionally for physicians, because it demands a personal evaluation and a personal decision that will then become quite public. The easiest thing in the world is for anyone to decide someone else is overcompensated -- usually such determinations are made with a paucity of information about what that person's life or job really entails. So in general, second- or third-party opinions about the level of another's compensation are nearly worthless. What matters is what that individual feels is the value of his or her own efforts. This is the crux of the entire issue, and a point of vulnerability for physicians.

If brought to the exercise, physicians would do a credible job of assigning a reasonable value to what they do; however, it is the next step that becomes our waterloo. Once a determination of fair reimbursement is made, the next step is to ensure that it is received. Doctors have so strongly ingrained in their practice ethics the concept of selfless service to others that any consideration of themselves is immediately branded as "self-serving." So important is this appellation to physicians that, once so branded, they immediately crumble and cease their advocacy. The vast majority of physicians would simply prefer to suffer quietly to the point of leaving their practices and starting anew in some other field rather than being publicly labeled as "self-serving."

We must learn that a demand for fair reimbursement isn't self-serving but is the only possible way to sustain our profession. There is no way that we will be able to attract young people to the rigors of the preparation for and the life of a physician if they will ultimately face the constant reality that they are not fairly compensated.

The battle to secure fair reimbursement will not be easy and will certainly be filled with a generous helping of rancor. The entitlement bunch feel that their first entitlement is to the fruits of the labor of others. When this is denied, they react ferociously and viciously. We will need to remember the childhood admonition regarding sticks, stones and words. We certainly can prevail, because fairness is precious little to ask; however, we will need to be steadfast and resolute. I would suggest our first salvo be over the "pay for quality" scam. We should simply say "Thanks, but no thanks" to this insult to our basic intelligence and professional integrity.

William G. Plested III, MD is a thoracic and cardiovascular surgeon from Brentwood, Calif. He served as AMA board chair during 2003-04, and as AMA president during 2006-07.

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