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The Problem:
Lack of motivation for Doctors to actually improve the health of their patients.
Principles:
1. There should be rewards for good behavior and punishments for bad behavior.
2. People who do a better job should get promoted.
The Social Invention:
I know doctors are generally well
intentioned, but the system is not set up to reward the best Doctors. I guess with lawsuits it is sort of set up to punish bad doctors, but we need the carrot of a reward, not just the threat of a stick.
Free Market:
If people really had choice you could let the free market fix it, but they don't. If we go to a managed system (saying that our system is not already managed) we should not forget the lessons learned in the free market. "Economic reward" (or if your a socialist "greed") can be used to reward people for doing their job well."
Ways of using the free market principles (rewards for good behavior) in medicine.
1. We could pay doctors according to how healthy their patents are. If doctors were assigned a certain number of patients, in a certain age group, they would be paid according to an algorithm that would endeavor to pay the most to the doctors that had the healthiest patients. The algorithm may need to be complex taking account of patient circumstances. Statisticians would have to be involved, and because doctors may only see about 15 people a day, it may take a couple of years of statistics to see the good doctors from the bad doctors.
2. We could require all patients to do feedback, and allocate pay bonuses based on the patient feedback.
3. Pay doctors according to the health gain of their patents, as apposed to just the overall health. This would eliminate the desire to only take healthy patients (if doctors were assigned patients at random this wouldn’t be an issue).
4. “Consider capitated practice plans. The doctor is paid X amount to care for y patients. Sickness is expensive, and will use up the allocated X more quickly. The doctor must keep patients well, because that is cheaper. Since the doctor has already been paid, there is no incentive to take on more patients to increase his pay, do more expensive procedures / tests to increase pay, etc. In such practices, patients might be asked to come into the clinic every day for a blood pressure check, until it was controlled. Pointless lab tests are kept to a minimum, while those with potentially high payoff (in terms of keeping down expenses) are used frequently.”
Reasons to agree:
1. It would be interesting, potentially, to have available wellness statistics for doctors, just as we do for certain treatments.
2. This is a no-brainer. There should always be a carrot and a stick approach towards everything that leads to better societies.
3. In business you make more money the better you do. In health you make more money the sicker your patients are.
4. When I go to the Doctors office I never see them mention how much test cost. They get paid for the number of hoops I have to jump through.
Reasons to disagree
1. Only a minority of a person's health depends on health care.
a. Reasons to disagree
i. That is the whole point. We spend lots of money on things that don't actually help our health.
2. “Further, there are whole segments of the profession (from allergists to plastic surgeons to chiropractors) that absolutely, positively depend on the near substance dependence type (re)visiting patterns of their patients” (whatever this means. Am I stupid, or do these words not make any sense? I would post reasons to disagree but I don’t really understand what he is saying.)
3. “Anecodotal evidence to the doctor's effectiveness already drives patients, so at least in theory what the doctor makes does depend, if indirectly, on what the doctor does. So on balance, I don't think that the idea has much new to offer.”
a. What anecdotal evidence? Are you saying word of mouth? I would guess only 5% of doctors are recommended. I bet the rest are just picked off of a list “in network providers.”
4. “I should expect that Harold Shipman had a fairly high healthiness rating for his patients, perhaps aided by his statistically anomalous death rate.”
a. This system would not reward doctors who had a high percentage of patients who died. They have statically chances of living another 6 months, etc. Doctors who typically exceed the expected life expectancy would be rewarded, if their was a statically sound case, that the doctor was better than other doctors.
Origin of Idea
I had this idea when listening to an NPR story about how Doctors have no incentive to spend time with their over-weight patients in counseling them on how to live healthy lives. Doctors only seem to be paid when they give a prescription, or put on plastic gloves. Instead we should incentive-ize (pay) doctors to help their patents live healthy lives.
Other ways of implementing this principle
1. Teachers who teach more, should also get paid more.
2. Prisons that reform their inmates better, should be paid better. Statistics could be used, about which facility has the lowest repeat violent criminals, etc. Prisons could be viewed as educational facilities about how to control your temper. I image violent movies/music being banned. Opera, Dr. Phil, and a 24 hour soup for your soul channel being broadcast. If their was money in it, people would be competing who could come up with the best formula. Does Johny Cash music help sooth violent tendencies? Would motivational speakers help? All questions for the free market to fix.
How good is your doctor?
http://www.newyorke...tent/?041206fa_fact
A really fine article about the care of people with cystic fibrosis. How good is good enough? [bungston, Mar 08 2005]
Harold Shipman
http://en.wikipedia...wiki/Harold_Shipman
[calum, Mar 11 2005]
Reason to agree
http://www.wired.co...3.05/view.html?pg=5
A great article in the Bible (I mean Wired Magazine of course!) [myclob, Apr 28 2005]
Formerly baked in china?
http://www.huzanity...y/Health%20care.htm
only a century ago in China, doctors were paid by their patients when they were not sick. And he paid them, and took care of them, when they were. [spidermother, Jul 28 2009]
[link]
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[waugs], certain doctors become proctologists for the same reason Galapagos finches have different size beaks, and while a certain (perhaps even high) percentage goes into the medical profession because they like to help people, many also make a financial calculation. |
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Further, there are whole segments of the profession (from allergists to plastic surgeons to chiropractors) that absolutely, positively depend on the near substance dependence type (re)visiting patterns of their patients. |
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It would be interesting, potentially, to have available wellness statistics for doctors, just as we do for certain treatments. |
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As to the idea or lack thereof, anecodotal evidence to the doctor's effectiveness already drives patients, so at least in theory what the doctor makes does depend, if indirectly, on what the doctor does. So on balance, I don't think that the idea has much new to offer. |
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A slightly better idea would be to require all patients to do feedback, and allocate pay bonuses based on the patient feedback. |
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[half] - I was referring to your question of incentive. You
asked, what incentive is there if you're in a low risk group?
Hence my comparison to insurance. People in low crime
areas of housing, for example, still take out insurance.
People in low risk health situations may still have
incentive to use this system. |
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I should expect that Harold Shipman had a fairly high healthiness rating for his patients, perhaps aided by his statistically anomalous death rate. |
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And here I was hoping to get that for the proctologist/finch beak length comment, UB |
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This idea has been heavily bagged. It is already widely practiced. Consider capitated practice plans. The doctor is paid X amount to care for y patients. Sickness is expensive, and will use up the alloted X more quickly. The doctor must keep patients well, because that is cheaper. |
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Since the doctor has already been paid, there is no incentive to take on more patients to increase his pay, do more expensive procedures / tests to increase pay, etc. In such practices, patients might be asked to come into the clinic every day for a blood pressure check, until it was controlled. Pointless lab tests are kept to a minimum, while those with potentially high payoff (in terms of keeping down expenses) are used frequently. |
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One might argue (and I know you guys will, if I let ya) that this prejudices against sick patients. The same sort of labor intensive, "keep patients healthy" approach can work very well for sick patients. Linked find an excellent article from the New Yorker on the care of cystic fibrosis patients. It really made me think. |
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As re this idea - it is not outrageous. You folks that read the linked article - should these docs who perform better be paid more? |
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[blissmiss] Your career history gives me greater understanding of your nome de net. |
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<rant>I wish this would work for my dentist, I swear he's got a thing against me, I brush my teeth at least once a day, and when I go there, he's all 'hmmm, you need a filling', while my brother, who's older than me, hasn't had a filling ever.</rant> |
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When I go to the Doctors office I never see them mention how much test cost. They get paid for the number of hoops I have to jump through. |
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In business you make more money the better you do. In health you make more money the sicker your patients are. |
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"So, doctors who work in palliative care are paid nothing?" |
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I wish I was ind the medical field (I'm an electrical engineer) because I'm sure I would make more money, but to tell you the truth, I don't know what palliative care is. Your right would not work in every situation. |
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Statisticians would have to be involved, and because doctors only see about 15 people a day, it would have to look at a couple of years to see the good doctors from the bad doctors |
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"Doctors become doctors precisely because they want to do what the author states they have no motivation to do." You are right. However, perhaps just because they allready have the motivation to be good doctors, doesn't mean that good doctors shouldn't get paid more. |
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I often have to come back and make excuses for omissions on my part, too, so I see some revision as being okay. This site is a little bit wiki in that way. |
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I'm using my power to edit this statement that I made, "This website is amazing. I posted 4 idea, and on one hardly has voted that the idea is good, and every post is how stupid, immoral, and evil I am." |
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Your right. It does hurt your feelings when people don't like your ideas. I'm over that now, honestly. I think I am getting a thicker skin. |
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[Blissmiss], Yeah, where is that anno? I came back here specifically to re-read it. Perhaps post it again as part of an idea/your second anno. |
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Why don't we just let the free market take care of these things? Let doctors charge however much they want to, and let patients choose their doctor based on likelihood of being cured and price. Why is medical care different than any other commodity? |
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1. Everyone has a fundamental right to adequate health
care, in the opinion not just of me, but of many. |
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2. Not everyone has a choice as to whether they need
health care. |
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Some criticism of this idea is on the basis that doctors are,
or should be, motivated soley by helping people. The
plain fact, while not completely opposite, is still
somewhat contradictory to this. A doctor with shares in a
pharmecutical company is a counterexample to this ideal. |
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I see my annotation was removed as well. Do you want people to bother saying anything? If you're just going to pull comments you don't like, why should anyone bother annotating? |
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Fuck that noise. I won't waste my time. |
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With a number of anno's now deleated on this thread-it makes no bloody sense. |
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I am sincerely sorry about deleting comments. I will not do it any more. I did not think that people would know. I figured they would make comments, and never look at this idea again. I have not looked at other people’s comments (I am very self centered) but judging by the amount of categories, I figured their would be so many ideas on this site, that people would just post their comment, vote, and never come back to the site again. “I know the I’m sorry, I never thought you would find out” apology is not the best one, but I did not think anyone would take it as an insult. I thought that if I addressed negative comments in the text of my idea, that they were no longer needed or relevant. I know the “I did it because I could” apology is also a bad one, but I figured if they were going to let me delete other people’s negative comments, why wouldn’t I? What is in it for me to let sarcastic comments about my intelligence or my idea stick around. Their was once idea from someone who hadn’t voted yet, that I did not mean to vote. I was just doing it so fast, I accidentally deleted it. I had not expected the sense of community that this site has. I’m not trying to suck up. By community, I did not think that you would stay on an idea for a length of time, or came back to read the comments of other… |
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"With a number of anno's now deleated on this thread-it makes no bloody sense." |
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Also I deleted the anno's because I hate the "thread discussion method". It goes on forever, and with each new annotation, the subject changes. If you were to draw a tree diagram of the subject of an annotation it would go all over the place. I think annotations should be summerized in a reason to agree or disagree table, with the best annotations at the top. |
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My,We do have a lot to learn. |
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Welcome to the bakery Myclob. I think you might have set a first week record. Cheers! |
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// I did not think anyone would take it as an insult. // |
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What the fuck did you think, then? bliss pours her heart out on a topic that she has lived and breathed, and practically gives us views into her soul, and you just push delete and think no one will notice? Christ. |
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I haven't had anyone in my twit filter for some time now, but I just added you. Don't bother responding, I won't see it. And I won't know if you delete this annotation, so knock yourself out. |
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Waugsqueke, I will not delete your comment. I will never delete another comment on any of my ideas. But it seems like you got a little too mad, for just having your comment deleted. I tried to encorporate most of the main ideas in the text of the idea. |
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His anger was not so much about his anno being deleted. His skin is far thicker than that. |
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His anger is strengthened by the fact that he, and the others, who's annos you deleted, feel strongly when a person actually sits down, opens the door, and lets you, a complete stranger into their life. Their most intimate, private space. |
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Do you not understand that the way this site has become a community, is because we do know a lot about one another, and because even if there is a difference in opinion, we still respect one another. |
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When I know that one baker is hearing impaired, or another is dreadfully ill, and the list goes on and on, it is because at one time or another, they opend up to the entire world, about their disability, or sickness, but felt safe. We cared. |
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You still seem like a rational human to me, who just does not understand the bonds that can grow in 5 years. |
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Did you know I actually took the plunge to logon and have a halfbakery name, two days after 9-11? It was because of the out pouring of worry over a baker in NYC. People from Aussie, England, Alaska, etc were moment by moment praying for him, and his boy, and his wife. |
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Rule number one, the votes don't count. Rule number two, respect each person enough to leave their annons standing, unless they are insulting to you, on a personal level. Rule number three, laugh. Thinking, laughing, respecting, and co-existing, is elementary. Coming up with an idea that will blow the pants off folks, is secondary, and very difficult. |
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You can make new friends here who will defend you like a pitbull. |
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You can not make new friends here when you, delete heartfelt words, use your arrogance as a very, very weak defense, and have the pitbulls, come after you, everytime you speak. |
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The choice is yours. I am still mad that you destroyed, in one click, what took me over an hour to word, and an hour before that, to think through. |
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Be real. But don't try and immediatley try and fit in. You have had a rocky start. |
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Have you read Krelnick's "Halfbakery 101.5? It has received wonderful critical reviews by new comers. |
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Best of luck to you, as you either grow, or go. The dent you will leave, if you go, will be forgotten in less than 2 hours. |
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The impact that you could make, might be amazing, even to yourself, and last for a very long time. |
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Ball's in your court. Are you an arrogant poop, or a new person finding their way? |
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I have learned more about myself here, than anywhere else in my life. I think, I have finally even learned tolerance. Both in my own behaviors, but more importantly, in others. Hence the lengthy post. |
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I hope you can find your way here. Desert Fox might be a good reference for you. He had a rocky start. But now, well, he really is Desert Fox. |
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I am as one with calum.
These sort of schemes provide what are known as 'perverse incentives' whereby the object of the exercise is diverted away from the main point; in this case to provide medical care; and becomes focused upon methods of filling out your statistical returns in order to gain as high a score as possible.
They also, in the manner of most statistics, tend to lead to more questions rather than providing any real answers and, before you know where you are, you've spent a vast fortune on statistic-analysing bureaucrats like me when you could have spent it on training up more doctors to reduce the workload on the medical profession. Fishy. |
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Hmmm and back to the actual idea... So what about them doctors? They look like they are on a winner --- what do you think chuck? |
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I'm sorry. I want to stay. I hope my account doesn't get deleted. I got a lot of people mad, the first day I realized all of these comments to the right of my idea, are actually about my idea. I have been thinking for the last 7 years of getting red of the thread discussion board. I thought that it changed subjects too much. I wanted to create a list of reasons to agree or disagree and have people vote on different aspects of each reason, with the best reasons going to the top of the list. I think about this all the time, and so naturally when I got to this website, I just went crazy. I deleted about 10 ideas, and tried to summarize their main points in my main text. |
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I honestly wasn't expecting any of these people to come back to my idea. I didn't mean to change the subject, you guys were going some where. And that is the problem, these post come in chronologically, but really they should tree off into different subject, so this post should not interrupt the post about doctors, this should just respond to the people who were angry at me. But I guess it's not to hard to keep track, in your mind what your posting to, but wouldn't these ano's be cool if they branched out? |
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What the hell are you talking about? |
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[myclob], it works very well this way - if it were 'tree'd' then you would have to make an effort to find out what people were saying. The things that people say may seem off topic, but it may only seem like that because of your point of view. I am often times educated by seemingly off-topic comments. |
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Your right, this website works pretty well. |
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It really does, [myclob]. So simple but so effective. |
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actually, I think that [myclob]'s idea of tree anno's might be kinda cool. |
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That's been discussed - look in the [halfbakery] category
somehwere. It wasn't really popular. |
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[admin: copyrighted material removed. See wired.com link to read what had been posted here.] |
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Since I too am new I was wondering if there was a way to bring the deleted annos back. I didn't look at this idea for a couple days and missed a lot of what happen. |
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[myclob] Have you been writing that up all month? |
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[myclob] as much as said that he enjoys deleting annos and ideas that go afield of the originality that spawned them. I agree in substance, and have dallied with the practice myself. In a high-volume text environment with all or nothing deletion an act of choosing requires study, patience, good judgment, and a thick skin because occasionally you'll get reamed for deleting someone else's pithy remark. I've used my own 'pithy remarks' as placeholders to which I intend to return and post comment after consideration of the idea at some length. I doubt the publisher of this 24-hour site intends users to conclude all study before bed. But I digress (risk deletion :-) |
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The nine, ten, or so prospects [myclob] cut from the Wired article that bespeak industry change in the US medical system are solidly underway. Overriding any industry flaw mentioned in the preceding text is the role of general hospitals as resource wasters -- in quantity consumed and in efficiency of consumption. By nature, the systems in place are net consumers of resources built on ideals for compassionate care of illness. Doctors will have to be efficient to survive the upheavals arriving at their health care industry doorstep. |
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[myclob] I just noticed the link that you added to wired magazine, and realized that you took the entire article and pasted it in your anno, and I have some advice.
Firstly, you should definitely give credit to the writer within your anno, so people do not mistake the anno for your ideas and writing.
Secondly, why would you paste in someone else’s entire article?? If you find someone that supports you opinion, good for you. If you find someone that supports your opinion, and has also written an article about it, great!, and you can even create a link to it, which will allow people to follow the link and read the source (letting the writer get credit for his work). What you did was take an article that presents a scenario for what may happen in the future, a future that your idea *might* help bypass. This article does not add anything to your idea, nor does it prove or disprove it. It is interesting as supplementary reading, and so deserves a link, but does not do anything for the idea being discussed, so even if you did write it, probably does not belong in an annotation.
As it is you are just taking up unnecessary hard drive space, and passing off some else’s unrelated ideas as your own—not really what the annotation system is for. |
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Thanks for pointing that out, [brodie]. |
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Posting copyrighted materials here at length and without attribution is a serious no-no, [myclob]. Beyond the issue of underhandeness, you can get the site in legal trouble over it. |
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I did give credit to the writer of the article, I did not try to pass it off as my own, and it was relevant to my idea, not just as a side note. I posted it as part of the conversation, because I wanted for people to respond to it. I wanted it to be part of the discussion. I did not want it to be a side note. |
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totally off topic but I've been reading a
lot of ideas and annotations and a lot of
people say things like "welcome" or
"You're starting to get the hang of it the
bakery" etc., and I realized I haven't
introduced myself really. Hello. |
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[myclob] I noticed you have a lot of
bones to croissants. I'd just like to say
that perhaps it is better to have many
people dislike an idea than not give a
thought to it. |
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Thanks for the feedback. I guess I don't even agree with all of my ideas, I just have them banging around in my head, and it helps to get them out. |
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Back the original idea, I will bone it due to an idea sprouting from 1 thing in the idea description: |
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//while those with potentially high payoff (in terms of keeping down expenses) are used frequently// |
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I think that this encourages Doctors to just cost cut, since they get paid more for the less they spend. Therefore there is a clear conflict of interest; if they use the expensive but better method (not always true but in a broad sense right) they get less money personally, but if they use the cheaper method, they gain money personally at the slight expense of the patient. |
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I think that in a decision between themselves and the patient too many will choose themselves. They will then cut costs and in doing so decrease their standards of service. This will invairibly lead to a slightly higher mortality rate and then we are throwing away lives. |
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That in my view is unacceptable. |
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Whilst I sympathise with the carrot and stick theory, I feel that in this case, this carrot won't work. |
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I suggest not tying it to salary, but instead encouraging small scale schemes with no set rules. |
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E.g. John gets a congratulations and hamper of food for him and his wife (or whatever scenario and reward) for being a great team member and specifically helping cure a distessed patient who was convinced they would die, John cheered them up and their lack of depression and therefore placebo effect boost helped them get better. |
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As opposed too, John gets £250 for raising his level of healed patients by 10%. This inspires a bad type of competition, where to win people must beat each other by competing for a limited number of resources (i.e patients). Also we have the problem of people trying desperatly to get patients who are barely ill. |
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I know you tried to deal with this by the health improvement not just cured idea but how do you measure health? Sounds too difficult to judge. |
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My idea (hopefully) encourages people to win with no boundries or rules. They win by just being noticed for being good. And (gosh this sounds corny) there is no limit of goodness to compete over. |
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So there you go, sorry but [-] from me for encouraged corner-cutting. And a ridiculously long post with a whole new idea on it. |
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By the way, having read about [bliss]'s post, I'm really kicking myself about missing it, can it not be reposted or undeleted? |
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The principle of merit pay makes sense for most occupations, but what if you're a sickly person in need of a doctor? No doctor would want to touch you for fear of screwing up their "healthy patient rating". |
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There's an analogy in real life that mirrors this enigmatic little problem. Sometimes the best doctors loose the most patients. The sickest patients are sent to the best specialists, so the best specialists have the sickest patients. The group of patients that's the sickest has the most deaths. Therefore the best doctors somethimes have the most dead patients. |
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I'm especially qualified to comment on such subjects since I've got the word "doctor" in my made up halfbakery name. |
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By the way. How come "halfbakery" isn't capitalized? |
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I'm sorry to fishbone this one, but I have to. Mostly because I think [doctorremulac] makes a good point. Also, if we paid doctors by their patients health maybe people would want to pay teachers for their students intelligence. And just because you have a great doctor doesn't mean you are willing to do all the PT exersizes and stuff to get the benefits. |
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Hmm, I wasn't the least bit sorry to fishbone it. |
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re: "but what if you're a sickly person in need of a
doctor? No doctor would want to touch you for
fear of screwing up their healthy patient rating" |
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I already explained that any good algorithm would
take into account the initial health of a patient,
and track if their health improved. With a Doctor
seeing you twice a year (more than average), for 1
hour a visit (more than average), a doctor would
have 1040 patients a year. That is enough to make
up for any individuals, and get at the root quality
of the doctor. |
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Did you not read anything on this page? |
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re: " Sometimes the best doctors loose the most
patients. The sickest patients are sent to the best
specialists, so the best specialists have the sickest
patients." |
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What the hell are you talking about? First of all you
assume that this won't work, because doctors
would not accept sick patients. Then you say this
won't work because good doctors are assigned the
sickest patients. Which freaking system are you
making assumptions about? The system where
doctors are assigned patients, or the ones were
they are able to choose their patients, because
you can't change scenarios in the middle of two
different thought experiments... |
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If we had a system where doctors are assigned
patients, your first scenario goes away: doctors
are no longer permitted to deny sick patients. If
doctors are allowed to chose their patients, your
second scenario goes away. |
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I have read that in China doctors have been paid while their patients are healthy, but get less when they are sick, on the assumption that the doctor is not doing such a good job. I've not been able to find more than hearsay evidence online (link), and it doesn't seem to be mainstream practice now. |
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Perhaps this would work best in a village-like setting, where one doctor has a fixed number of (potential) patients. |
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I can't remember if i've mentioned this before, but that was my initial plan, sort of. When i qualified, i planned to set up a group of alternative practitioners who would be able to offer to treat a wide range of conditions which i as a herbalist couldn't, get people to commit by paying an annual fee, then treat them for nothing. This didn't work because i could neither find the patients nor the practitioners willing to make such a commitment.
In a way, it's quite a relief because of my lack of faith in a lot of alternative therapies. |
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The 27 negative votes are likely brought to us by the AMA. |
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I like this idea with all its flaws. |
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