Just as in the previous post Megan McArdle is generally right but makes an error, the same can be said about this post from Ezra Klein on health care. Ezra looked at a Kaiser/NPR poll on health care and does make some good points, such as questioning why people have such little interest in “in implementing the findings that emerge from cost effectiveness studies.” In this case it is more common for physicians than for the general public to be encouraged by cost effectiveness studies as we realize how much is done without good evidence. We want the data to make the best choices for our patients.
While Ezra reads a lot about health care and is very knowledgeable about the subject, such reading is often not a sufficient substitute for actual experience. This leads to his puzzlement over one issue:
Ezra writes in response to this question:
Honestly, I’m surprised patients even have an opinion on that. And it might be a very weak opinion. But for now, the public prefers that doctors get paid for each thing they do than on a salary basis. They prefer, in other words, that doctors have an incentive to do more rather than do less.
Here the majority of Americans are smarter than Ezra. Many have experienced the horrors of the HMO era in which doctors were actually paid based upon how little care they provided. Many also see the difference between the more old fashioned model of doctors in private practice as opposed to the increasing number of doctors who are employees paid a salary. They have seen the difference between a doctor who is motivated to work long hours to care for their patients and salaried doctors who check out at 5:00.
Imagine the negative incentives for being paid a yearly amount regardless of what is done. I’m often at the office past 8 p.m. to see people who call with problems late in the day. If paid a fixed salary most doctors would tell them to take an aspirin and call (or preferably don’t call) back next month. I’ll often wind up spending a half hour to an hour with a patient who is having serious problems. If paid a salary doctors are encouraged to see the highest number of patients possible in as short a time as possible. The medical offices run by the local hospital (which has bought up most of the doctors in town) has nurses with stop watches monitoring office calls and knocking on the door to end the visit if it lasts over fifteen minutes!
Sure, when paid fee for service for taking care of patients this could lead to incentives to do too much to make more money. This is reduced by both utilization controls and by the fact that there is so much more to do than we have time for. Of course, as in the previous post, I’m writing from the perspective of primary care. There is undoubtedly far more waste in some of the high-priced procedures as opposed to primary care offices, but this is also the situation which most people are probably considering when responding to poll questions such as this.