Salaried Employed Physicians Can Take the Lead on Health Reform?

The Disease Management Care Blog would like to introduce you to two alternate realities.

In the first reality, physicians own the bricks and the equipment that make up their clinics. They hire and fire their office staff members. They don't mind fee-for-service payment systems, because the harder they work, the greater the reward. "Pay-for-performance" generally results in greater practice income because they're already doing a good job unless it's Medicare. They like their patients and their patients like them. They like being in control of their own destiny.

They're anxious about health reform. They're paying attention.

In a JAMA commentary about an alternate reality written by the former New England Journal Editor-in-Chief Arnold Relman, physicians refer to themselves as "providers." They've been told about the strategies underlying their employer's capital allocations thanks to emails and evening staff meetings. Their input on human resource issues is generally not expected or necessary. They're paid a market-based salary and are expected to generate market-based patent care revenue. The details of pay-for-performance have been negotiated for them by their administrators with the insurer's administrators, unless it's Medicare. Patients populate their appointment slots. They don't mind not being in control of their destiny, just so long as they can get home by 5:30.

They're clueless about health reform. They're not paying attention.

In its travels, the DMCB has found that docs who are in physician-owned settings, thanks to their sweat equity, are far more likely to be engaged in health reform. That passion is one reason why the American Medical Association remains such a potent political force. The assumptions by Dr. Relman that salaried/employed doctors will make hospitals virtuous, attain consumer loyalty, exude professionalism, control costs, increase quality, manage global contracting and bypass partisan gridlock is silly for a single reason: with some notable exceptions, docs who go into salaried positions are, on average, less interested in the issues driving health reform and the business of medicine. Not having to worry about it is why they've agreed to be salaried and employed in the first place.

That's the real reality.