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Your Disease Can Kill You in More than One Way

by G. Keith Smith, MD

I’ve been asked a lot lately about “outcomes.”  The federal government is going to start paying physicians based on outcomes, it seems.  ”Outcome-based medicine” is a recipe for disaster.  Here’s why.

Patients are all different.  Contrary to what Washington bureaucrats believe, treatment must be individualized for individual patients.  That means that outcomes are going to be only partially under the control of the physician.  We had a patient that developed a foot infection years ago because she found that her pain was best relieved after her bunion surgery if she let her small dog lick her wounds.  Yet according to the brainiacs in D.C., this wound complication would reduce our payment for the care provided!

Now put yourself in the physician’s shoes.  He now knows that he is going to be “graded” and paid for his outcomes.  What chance does the patient with multiple system failure, someone whose likelihood of a good outcome is bleak if everything is done perfectly, have getting in to see a doctor?  If you are seeing this as a rationing tool you get a gold star!

“I’m not about to operate on that train wreck!”  ”It will kill my numbers!”  Can’t you just hear the talk in the doctor’s lounge?  Physicians employed by hospitals will be the first to run from the tough patients and the tough cases, as their loyalty is to their boss, not the patient.

Paradoxically, doctors who are doing sham surgery will be the ones with the best outcomes, as their patients, many of whom don’t need surgery in the first place, will exhibit great, basically perfect outcomes.  Physicians who don’t do unnecessary surgery will be pushed to do so to improve their “scores.”

“Pay for performance” trends in medicine are not a good idea in my opinion.  Paying based on patient outcomes will have perverse effects, not the least of which will be the complete denial of care to the very sick.



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