This eye surgeon describes an example of one of the perverse incentives he sees in hospitals. This sort of thing is a common problem in big bureaucratic systems. It's probably one of the reasons for medical care being more expensive than it needs to be. (This doctor is in the U.S.) "I realized that I am becoming more and more penalized for being efficient in the operating room. Case in point, this was my schedule behind me, from a week ago. I have four cases signed up. And the first three cases I was finishing early, and I was banking a lot of time, and by the time I was reaching my fourth case, I had saved up about an hour, and I was an hour ahead of schedule. So, you would think that I'd be able to go home early and enjoy the rest of my day, for being a good surgeon. However, that's not the case. What happens is I get, like, a little friendly tap on my shoulder from the powers that be, saying that they looked over my schedule and they saw that I had finished earlier. I don't have my full day blocked. And that I can now drive 30 minutes away to a different city and open up and afternoon clinic and see patients. My other option would be I would be asked to burn accrued time off, or 'ATO', so that I can have the rest of the day off. So the message you're basically sending to an efficient good surgeon is that the better you work, the more work you have waiting for you at the end of the day. So there's really nothing you're looking forward to, and if anything you are incentivized to take your sweet time. But by taking your sweet time, you are being exceedingly wasteful. So longer case times are very expensive. Longer case times means patients are under general anesthesia for much longer, potentially exposing them to more risk. But this is something that physicians are tempted to do, they can just schedule their surgeries in blocks much longer than times that they need to actually complete the case. So that they can get to the end of the day so they don't have to go to the clinic." https://www.tiktok.com/@drpark524/video/7405035121104997662?q=drpark524&t=1725328697193 posted August 19, 2024 "So this is a real life example of how good doctors are disincentivized to do what's best for the patient. This is a real life patient that I saw about a month ago. She presented at my clinic while I was on call. She had a bilateral retinal detachment. Meaning both her eyes were having retinal detachments at the same time. This is a site threatening condition. Patients go blind if this isn't repaired on an urgent basis. Now there's two ways to go about this. I could be lazy and not disrupt my afternoon clinic, take my time, see everyone that's scheduled, and just have this patient go to the operating room after hours. I can repair and bill for two retinal detachment surgeries after hours. Uh, everyone benefits, the surgical team gets paid 1.5 times their hourly rate. I get a ton of 'ATO'. My afternoon clinic is not disrupted. However, the patient's recovery is gonna be god awful. So both of her eyes will be essentially blind for the duration of six to eight weeks while a big gas bubble is in her eye. The ideal thing to do for the patient would be to just repair this in clinic with a pneumatic retinopexy. It is dirt cheap and super fast recovery. This is just five weeks after the procedure, we use a much much smaller gas bubble so the patient can see and remain fully functional during the recovery process. It screws me over because this is a quite difficult, very technical procedure that I need to do in the midst of my really busy afternoon clinic. And that's very stressful for me. And the unfortunate thing is I don't get paid extra, because this is done during my clinic block. So no 'ATO' for me. However, this procedure is so cheap, because it doesn't involve the OR team, that my department is saving about 8 to 20 thousand dollars for me doing this. Everybody wins except for me. (patient and department) " https://www.tiktok.com/@drpark524/video/7402438723511602463?q=drpark524&t=1725328697193 drpark524 posted August 12, 2024 Ophthalmology Dr. Park, Retina Surgeon
I wonder if this is relevant: In healthcare there remain these three - prevention, cure, and long term treatment and the most profitable of these is long-term treatment.
In some types of cases it could be issue, but usually not. Some people accuse HMOs (basically like a pay in advance service for healthcare) of wanting to the patients to die so they don't have to keep spending money on expensive ongoing care for sickly older people. Some people suspect it could be an issue in the pharmaceutical industry, cheaper to develop ongoing lucrative treatments than a single pill that would cure the disease. But hospitals are usually not thinking that way. Doctors usually do not think that way either. Except perhaps the very most unscrupulous ones. The type of issue brought up in the opening first post is that sometimes doctors will want to break up one appointment into two, just so the doctor can bill more money, even though the full procedure could have been done in one visit, at the same time. Or the doctor might be financially incentivized to choose a procedure that will cost more money, or require a longer ongoing treatment time for the patient. Doctors usually have more than enough patients and are not in need of causing sickness to get more business. The real issue would be amount of money the doctor gets per each hour of his precious time. A far bigger issue is that in some cases doctors may not properly treat a patient because they are in a rush for time and do not really care. But they are not doing it to try to make the patient have to come back. The doctor already has more than enough patients, with most doctors working long hours. In many cases at hospitals, doctors may routinely recommend or order tests and procedures that may not be necessary. Sometimes there is a financial incentive. In other cases the doctor is just worried about legal liability. And yet in other cases, it's just the easiest decision to make for the doctor and will require the least amount of time or thought to treat the patient, but may not really be best for the patient.
This isn't a problem that's unique to capitalism. This type of problem can be found in any large bureaucratic system, whether private run or government run. Indeed, in some cases there may actually be greater incentive in capitalism for this not to happen, because it can eat into the profits of the hospital, or insurance provider.
There’s greater incentive under capitalism to not squeeze every once of productivity out of a worker than under different systems? Okay.
I'm not sure we are going to get perfection, but so much of life is heuristic I'll just take a guess. Most doctors and most people have integrity, so it is usually best if the professionals run their own organizations. People often veer to a bureaucratic left, with organizations run not by the owners but by the government and that often doubles the problems because not only is it run by people not working in it, but also fails to reduce waste. Pure profiteering would be the far right and doesn't work all that well once the profiteers, gain a monopoly. Middle of the road economics leaves the employees with a fair amount of latitude and control over their own lives.
Although a very imperfect country, that's why we left it, and set up our own equally imperfect country, one thing in England people should become familiar with is the National Health Service. It has had a lot of problems but it is still a good thing and still functions.
