Superior pay for non-performance model threatens dermatology, society

Zoe Diana Draelos, M.D.What would happen to society if people were paid more for doing less? Would people work harder and harder to get paid less or do less and less to get paid more? I think this question demands a large, properly powered, cross-sectional, multivariate, multi-generational, prospective, case-controlled study. This is a very important study because we are instituting superior pay for non-performance as the new model for many segments of our society, including medical care. Dermatology is at the forefront of the superior pay for non-performance medical experiment, as we are fortunate to take care of a resilient organ that is rapidly renewing and easily accessible for treatment, thus minimal treatment or lack of treatment can be tolerated for a longer duration without increased mortality. (Remember that reduced morbidity as has no role in the pay for non-performance model.)

In my community, the battle for insured lives is heating up fast. The local hospital, which went bankrupt, is owned by the University of North Carolina at Chapel Hill Healthcare System, also known as the Tarheels, while the large multispecialty community physician group, that also went bankrupt, is now owned by Wake Forest University Healthcare System, also known as the Demon Deacons. For those of you who are basketball fans, we now have a NCAA Final Four rematch between two powerhouse ACC teams. Who will win? Stay tuned. The battle will be won by the institution that is able to charge the most money to insure the largest number of lives for the least expense, thereby instituting a successful accountable care organization (ACO). This goal can only be achieved by strict adherence to the pay for non-performance model.

More from Dr. Draelos about insurance: Shrinking insurance formulary limits Rx options

Next: Economies of scale

The economies of scale leading to superior pay are only realized in huge ACOs that cover large numbers of patients who are healthy or face entry barriers to the medical system. Since most everyone has a dermatologic issue (unwanted nevi, less than optimal scalp hair growth, brittle nails, seborrheic dermatitis, facial acne, etc.), “healthy” and “unhealthy” people seek care. Patients love to see the dermatologist to improve their appearance, alleviate their itching, and increase their social acceptability by treating visible skin disease. While treating these dermatologic conditions improves patient quality of life perceptions, it does not lead to decreased healthcare utilization.

The best way to deal with dermatologic issues in an ACO model is to have the primary care provider tell the patient their psoriasis is really very minor, not worth treating, and it is unnecessary to see a dermatologist. If the lucky patient does happen to get a referral, the best way for the dermatologist to function in an ACO model is to tell the patient that their psoriasis is really very minor and not worth treating. Marginalizing all medical problems that will not kill the patient in 72 hours is the best tactic to maximize ACO performance. In other words, do nothing until you anticipate malpractice problems. The best pay and ACO corporate accolades will be achieved through non-performance.

What does this new philosophy mean for our specialty and our society as whole? I lobbied for dermatology issues on Capitol Hill last month and met with an aide half my age who told me that my concerns regarding tanning booth use by minors were interesting. I argued that if CMS wanted to better control the burgeoning costs of treating actinic keratoses and skin cancers, measures should be taken early in life to prevent their formation. He told me in a joking tone that a better idea would be to give minors free cigarettes thereby shortening life span and reducing utilization of Medicare services. I thanked him for his time, realizing we are at a moral crossroads in our country regarding the value and quality of life.

We are sending some strong, rather dangerous, messages to our future generation. We are telling them the quality of their life is expendable based on the financial resources we elect to spend, yet we are expecting their full commitment to pay into the system with insurance premiums, Medicare taxes, Social Security deductions, and payroll taxes. We are taking the best and brightest of our future generation and training them to become physicians where superior pay is given for non-performance. It does not take long for enthusiasm, ingenuity, industry, compassion, and drive to disappear under such circumstances. 

I do not think we need the study I previously proposed. In a society where people are paid more for doing less, you simply get less. Superior pay for non-performance will implode dermatology, medicine in general, and society.

For more on similar topics, read: 

Predicting the future of dermatology

Navigating the healthcare system