| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
Guest Access | Sign In via User Name/Password
|
|
|
|||||||
Guest Access | Sign In via User Name/Password |
|||||||||
Philadelphia, PA
Richmond, VA
Dr. Goldfarb is Professor of Medicine, University of Pennsylvania School of Medicine. Mr. Higgins is Executive Director, Department of Internal Medicine, Virginia Commonwealth University.
Correspondence to: Stanley Goldfarb, MD, University of Pennsylvania, 3450 Hamilton Walk, Philadelphia, PA 19104-6087; e-mail: stanley.goldfarb{at}uphs.upenn.edu
One of the greatest pieces of economic wisdom is to know what you do not know.
John Kenneth Galbraith
Economic research suggests that relatively minor components of a physician’s capitation income could influence physician behavior.1 Moreover, when faced with the dual tasks of caring for patients’ physical well-being and bearing the financial risk of their care under managed care contracts, physician-owned groups seem to gravitate toward the same devices used by insurance companies to save costs. These devices include the use of a primary care physician as a gatekeeper, preauthorization programs in which nurses or physicians judge the appropriateness of referrals for specialty care or complex and expensive diagnostic procedures, and, to a lesser extent, the creation of guidelines or other educational tools to help clinicians provide care.2
These observations about physician response to costs-of-care contrasts with data suggesting that when physicians are not responsible for the cost of care, they do not place a very high value on those costs. In a survey conducted in California,3 most of the 1,100 physicians surveyed thought that only the physician and patient should decide whether a treatment is "worth the cost," and more than half also thought that the physician had a duty to offer any intervention with a chance of benefit, regardless of cost. In addition, many physicians, if pressed, will provide an intervention even when they think it is not indicated or not cost-effective.
Given these observations on the not surprising fact that physicians respond to economic incentives involved in clinical care, it is also not surprising that physicians would react positively to information on the economic benefits of optimizing the effectiveness and efficiency of the "business" aspects of their practices. In the current article by Bauer and French (see page 885),4 data are presented that should be very useful to clinical practitioners by giving them some insights into best business practices and the potential for such practices to improve their economic performance. Often, the lack of awareness of clinicians of the economic aspects of their work is startling. For example, as recently as 5 years ago, it was commonly believed by physicians that hospitals were paid a fee for service for performing diagnostic radiology and pathology when Medicare had done away with that payment system nearly 20 years ago! It must be noted that detailed data regarding the business function of specialty practices are relatively rare, and it is quite difficult for physicians in medical specialties to obtain comparison benchmarks for their practice activities. For example, the large organizations that supply such data, such as the Medical Group Management Association, tend to report data from large multispecialty groups rather than from smaller single-specialty practices.
While the results of the practice performance survey suggest "best practice" and outline some of the activities that might improve performance, they are just a first step, albeit a crucial one. Physicians can be as effective as any small business owners in managing or at least overseeing the economic aspects of a practice. But many other issues should be addressed in such surveys. For example, Nurse Practitioners and Physician Assistants are mentioned, but productivity increases and the expectations of these providers are not included. The questions are how much work should be expected from the mid-level provider and has the use of physician extenders proven to be more financially beneficial than, for example, expanding the practice by hiring an additional physician? Furthermore, many other potential best practices should be explored, including having the medical practice employ outside billing companies compared to the practice managing the billing or the economic benefit (or burden) of electronic medical records. Finally, and perhaps unfortunately, physician productivity must be assessed and data on the generation of work relative value units as a tool to assess physician productivity should be included in future surveys.
As Adam Smith pointed out in The Wealth of Nations, "Capital is increased by parsimony, and diminished by prodigality and misconduct". Controlling costs and optimizing effectiveness and efficiency are crucial in a business, and, for better or for worse, the reality of the physician as businessman must be faced. The information provided by the survey of pulmonary practices begins to inform this medical community of "what they do not know."
Footnotes
The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
References
This article has been cited by other articles:
|
|
 |
|
  S. Manaker, A. Ernst, and L. Marcus Affording Endobronchial Ultrasound Chest, April 1, 2008; 133(4): 842 - 843. [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
