Should Surgeons Be Paid on a 'Pay for Performance' Model?

These days, almost every sick-care business model imaginable is being considered in a desperate effort to cut costs before the meters run out. Despite the issues, paying surgeons by P4P won't be far behind.

The cost of cancer drugs continues to escalate. But that's not the worst part. In a lot a cases, they don't work. Now payers and pharmacy benefits management companies are pushing back and seeking deals with pharmaceutical companies that would set pricing for some cancer drugs based on how well they work.

Suppose surgeons got paid using the same model? If the operation didn't help, then the result would be a reduced payment or no payment. While none of us like to pay for things that don't work and are suspicious about retailers or other service providers offering money back guarantees, surgical pay for performance (P4P) would have its own set of issues:

1. Like drugs, operations work on some patients and don't work in others. Sometimes it has to do with the skill and experience of the surgeon. Sometimes it has to do with patient factors, most of which we don't understand.

2. No procedure has ever been performed where the outcome can be 100% guaranteed, possibly with the exception of an execution by lethal injection. Sometimes, even that goes wrong.

3. Defining outcomes would be difficult, if not impossible, on such a large scale. What is "better" and who decides?

4. Do we pay for "better" or "cure" or "good enough for government work"?

5. Suppose the patient has a complication that leads to an unsatisfactory result or has multiple comorbidities? Should surgeons get extra credit that goes on their permanent records?

6. How should patients be held responsible for not following postoperative instructions that leads to a less-than-satisfactory result? What about medtech and biotech companies that produce products that have minimal effectiveness? Should we also hold the FDA accountable and have them pay the bill for clearing things that marginally work?

7. What would be the impact on medical education and training knowing that having a resident doing most of the case under attending supervision might lead to no payment? Will surgeons have to attest to "hands on" time and bill out like lawyers bill for work done by different providers, like paralegals, junior associates, and senior associates?

8. How long do we wait to see if the operation works? Until "all the swelling goes down"?

9. What do we do with surgeons who get results worse than their peers or use technologies for which they are not trained?

10. Suppose you had an operation that didn't work? If you had the choice, would you go back to the same surgeon? Then what?

These days, almost every sick-care business model imaginable is being considered in a desperate effort to cut costs before the meters run out. Despite the issues, paying surgeons by P4P won't be far behind. Of course, doctors will resist. Some will offer it in highly competitive areas.

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