In 1964, the year before Medicare was enacted, what would you expect dermatologists to answer if asked to choose between the following two options for reimbursement:
1. the physician fee for an initial visit, or
2. the price of the medication prescribed (a tube of Hytone, 90 pills of branded erythromycin, or a syringe filled with 1.2 million units of Penicillin)?
The dermatologist would have chosen the amount of the fee for an initial visit because he would have received a greater amount of reimbursement for it.
However, in 2007, if asked this question, the same dermatologist would prefer to be paid either the cost of a tube of Taclonex, 30 pills of Solodyn, or better yet, a month’s supply of syringes of Raptiva, Enbrel, Amevive or Humira — rather than the standard fee for an initial visit.
Declining Power
The power of physicians to set prices for medical services has declined. Most physicians seeking recompense from HMOs are faced with a Hobson’s choice (no choice). They can take the HMO’s fee schedule, which implicitly deems medical services to be an interchangeable commodity, or opt out.
Dermatologists have increased their incomes (more than most other specialties) by seeing more patients in a workday mainly by hiring physician extenders to see patients and perform more cosmetic procedures.
It is unclear if the use of these compensatory strategies to maintain income will continue to work as other specialties add cosmetic services to their repertoires, a trend noted in a recent article in the New York Times detailing the extensive cosmetic, laser and Botox practice of an OB/GYN.
1 In addition, extenders (physician assistants [PAs] and nurse practitioners [NPs]) may some day have the right to provide care without a physician’s supervision, a situation already playing itself out between optometrists and ophthalmologists across the 50 states, with optometrists free in some states to perform eye examinations and some types of surgical (laser) procedures.
The pharmaceutical companies, however, have become more adroit at exercising their pricing power. They can set prices for medications covered by patents, mostly free from market competition, as unique goods rather than commodities. The pricing of drugs flows from the knowledge that most insurance plans will pay the price for a medication to which the FDA gives an indication, that is, until the medication’s patents lapse.
Even this power is eroding as insurance companies remove medications from their formularies, make patients pay more for branded medications and complicate the appeals process for the denial of a request for a medication. It is the patient who needs a medication to abate or cure a disease who faces the Hobson’s choice.
There were more than twice as many physicians per person in the United States in 2006 than there were in 1964 (to say nothing of PAs and NPs, whose occupations did not exist before 1964). The increase in the number of doctors has decreased the pricing power of each doctor. Physicians’ incomes as a percentage of per capita income in 1964 were between 600% and 700% of per capita income and are now at about 300% to 400% of per capita income. Medical services, for the most part, have become commodities by 2007. Commoditization has exerted complicated effects on the provision of medical care.
Cutting Time Spent on Procedures
Payments are made for CPT codes billed and not for the success achieved or effort involved in a physician’s intervention. The time spent providing a CPT service is supposed to relate the work of the doctor through the system of relative value units (RVU), but in actuality it is an invitation for the doctor to find ways to spend less time than the RVU estimates and thus enhance income.
A striking example of the collision of RVU and payments occurred in the mid-1980s in a hearing before Congress on Medicare fees. Representatives from the American Academy of Ophthalmology complained they were not being paid enough for performing cataract surgery, a procedure that once accounted for the most inpatient hospital days of almost any kind of surgery and is now done as an outpatient procedure. During the hearing, a Congressman asked what was a typical fee charged by ophthalmologists for cataract surgery. An ophthalmologist replied that $2,000 was the fee, on average. Then the Congressman asked how long it usually took to complete cataract surgery, and the ophthalmologist replied, “30 minutes.” This stunned the Committee.
Since that time, payment for cataracts has decreased year by year, and Medicare now pays about $350 for a cataract operation, opposing the notion that medical prices only go up. (Of course, more surgery is performed now, and the population is aging, so total spending for eye surgery has increased.)
The incentive to spend less than the recommended amount of time performing a CPT service — for which the only factors that limit billing for the service are doing it and charting it (in effect deeming it a commodity) — was recently underscored in the December 2006 issue of the New England Journal of Medicine.
2 There it was suggested that gastroenterologists who spend less than the recommended amount of time performing a colonoscopy find fewer adenomas. The minimum recommended time for a colonoscopy is 6 minutes, and the report found that gastroenterologists who spend 3 minutes doing a colonoscopy find a fraction of the number of adenomas found by gastroenterologists who spend 6 or more minutes on one.
Those who take 3 minutes undoubtedly believe they are serving their patients well, but the economics of the colonoscopy, whose reimbursement has been drifting downward, may very well explain the swift performance of the colonoscopy by some gastroenterologists.
It stands to reason that is is likewise the case that radiologists who spend 1 minute evaluating 15 11” x 17” transparencies of an MRI of the brain must be missing more than radiologists who spend 15 minutes looking at those 15 transparencies.
Experts and Neophytes Reimbursed Alike
Currently, medical fees paid by Medicare are the same for the department chairman or world-reknown expert as they are for the physician 1 day out of residency. Baseball players are paid different amounts based on their previous performance and seasoned lawyers bill at higher rates than neophyte attorneys. In medicine, this is not the case.
In fact, when Medicare was first enacted, neophytes got paid more than veterans because Medicare paid the usual and customary rate of a physician. If the department chairman at Harvard charged $300 for a service in 1964, then that is also what Medicare paid in him in 1966. Yet his fellow during 1964 and 1965 could set a fee of $2,000 for the service in 1966 when he became an attending and Medicare paid that. Payment for a service based on the usual and customary rate of a physician has gone the way of the Norman Rockwell doctor into the annals of medical history (or medical lore or myth).
In my last article on pricing medical services, I noted that independent physician associations (IPAs) often negotiate higher fees than the rack rate for their members. However, IPA’s fees are set in relationship to CMS’s fees, and IPAs’ fees will fall when CMS lowers the fees in its schedule.
So, for the time being, as a member of the Columbia Presbyterian Physician Network, I am being paid more now from Oxford and Cigna than when I was under the aegis of St. Luke’s Roosevelt Hospital. But I think — although I have not independently confirmed this — that a world expert on photobiology and photomedicine and chairman of the Department of Dermatology at Columbia and I are paid the same by Oxford and Cigna to treat PMLE. Interestingly, Aetna has a higher fee schedule for full-time staff at Columbia than for voluntary physicians who are part of the Columbia Presbyterian Physician Network.
How Will New Coding Decreases Affect Time Spent on Procedures?
We will see what effects treating medical services as RVU-defined commodities will have on dermatology now that there is a decrease in reimbursement in the 17000 series of codes for the destruction of warts, which will now be billed under 17110 and 17111, and actinic keratoses, which will still use 17004 with decreased reimbursement in 2007.
Dermatologists can bemoan these changes, but again, only a Hobson’s choice exists. The use of medical visits as loss leaders for surgical services — or, in other words, using 17004 to cross-subsidize the provision of medical care — is not an option for which the price paid for a service reified by a code is a commodity whose value must stand on its own. Unintended effects arise when medical services are interchangeable widgets whose prices are constantly bid down.
The cuts of reimbursement of 17004 will likely vastly cut into the income of pediatric dermatologists whose major procedures are the destruction of warts and molluscum.
A pediatric dermatologist told me that his gross income would fall by $60,000 if the Medicare fee cuts are replicated by commercial insurance. It is interesting to ponder that the nascent field of pediatric dermatology could be felled by a re-jiggering of 17004.
Will Commoditization of Cosmetic and Elective Procedures Occur?
The commoditization of cosmetic and elective procedures might occur. It did occur with the pricing of LASIK surgery, which was originally a procedure that commanded thousands of dollars and has now stumbled and fallen to hundreds of dollars.
If the internist of every patient offered Botox injections for glabellar lines, many of us would experience a decline in our patient base. Still, I think that the economic profits — that is profits when costs are accounted for —for cosmetic procedures will be greater than for medical services because the dermatologist has greater knowledge and power than an individual patient when deciding how much to charge, a power that is in the hands of the Centers for Medicare and Medicaid Services and the HMOs in relation to the pricing of medical services.
Although some movement has been made to pay for quality in medical care, such bonuses are usually about 10% and so far have only had a fractional effect on physicians’ incomes and practice patterns. When electronic health records become universal and the ability to monitor actions of a physician increases exponentially, this might change.
What Can We Say for Sure?
Not all dermatologists are paid the same to perform a service, yet medical services have generally been turned into commodities.
Ways to cope with these situations to maintain income and provide patient care have been developed, but the payments for medical services and the modes of the provision of medical care itself are in a state of dynamic flux.
The only sure thing that I can say is that medicine and the medical payment system will change as much in the next 40 years as they have in the first 40 years since the implementation of Medicare in 1965.
In 1964, the year before Medicare was enacted, what would you expect dermatologists to answer if asked to choose between the following two options for reimbursement:
1. the physician fee for an initial visit, or
2. the price of the medication prescribed (a tube of Hytone, 90 pills of branded erythromycin, or a syringe filled with 1.2 million units of Penicillin)?
The dermatologist would have chosen the amount of the fee for an initial visit because he would have received a greater amount of reimbursement for it.
However, in 2007, if asked this question, the same dermatologist would prefer to be paid either the cost of a tube of Taclonex, 30 pills of Solodyn, or better yet, a month’s supply of syringes of Raptiva, Enbrel, Amevive or Humira — rather than the standard fee for an initial visit.
Declining Power
The power of physicians to set prices for medical services has declined. Most physicians seeking recompense from HMOs are faced with a Hobson’s choice (no choice). They can take the HMO’s fee schedule, which implicitly deems medical services to be an interchangeable commodity, or opt out.
Dermatologists have increased their incomes (more than most other specialties) by seeing more patients in a workday mainly by hiring physician extenders to see patients and perform more cosmetic procedures.
It is unclear if the use of these compensatory strategies to maintain income will continue to work as other specialties add cosmetic services to their repertoires, a trend noted in a recent article in the New York Times detailing the extensive cosmetic, laser and Botox practice of an OB/GYN.
1 In addition, extenders (physician assistants [PAs] and nurse practitioners [NPs]) may some day have the right to provide care without a physician’s supervision, a situation already playing itself out between optometrists and ophthalmologists across the 50 states, with optometrists free in some states to perform eye examinations and some types of surgical (laser) procedures.
The pharmaceutical companies, however, have become more adroit at exercising their pricing power. They can set prices for medications covered by patents, mostly free from market competition, as unique goods rather than commodities. The pricing of drugs flows from the knowledge that most insurance plans will pay the price for a medication to which the FDA gives an indication, that is, until the medication’s patents lapse.
Even this power is eroding as insurance companies remove medications from their formularies, make patients pay more for branded medications and complicate the appeals process for the denial of a request for a medication. It is the patient who needs a medication to abate or cure a disease who faces the Hobson’s choice.
There were more than twice as many physicians per person in the United States in 2006 than there were in 1964 (to say nothing of PAs and NPs, whose occupations did not exist before 1964). The increase in the number of doctors has decreased the pricing power of each doctor. Physicians’ incomes as a percentage of per capita income in 1964 were between 600% and 700% of per capita income and are now at about 300% to 400% of per capita income. Medical services, for the most part, have become commodities by 2007. Commoditization has exerted complicated effects on the provision of medical care.
Cutting Time Spent on Procedures
Payments are made for CPT codes billed and not for the success achieved or effort involved in a physician’s intervention. The time spent providing a CPT service is supposed to relate the work of the doctor through the system of relative value units (RVU), but in actuality it is an invitation for the doctor to find ways to spend less time than the RVU estimates and thus enhance income.
A striking example of the collision of RVU and payments occurred in the mid-1980s in a hearing before Congress on Medicare fees. Representatives from the American Academy of Ophthalmology complained they were not being paid enough for performing cataract surgery, a procedure that once accounted for the most inpatient hospital days of almost any kind of surgery and is now done as an outpatient procedure. During the hearing, a Congressman asked what was a typical fee charged by ophthalmologists for cataract surgery. An ophthalmologist replied that $2,000 was the fee, on average. Then the Congressman asked how long it usually took to complete cataract surgery, and the ophthalmologist replied, “30 minutes.” This stunned the Committee.
Since that time, payment for cataracts has decreased year by year, and Medicare now pays about $350 for a cataract operation, opposing the notion that medical prices only go up. (Of course, more surgery is performed now, and the population is aging, so total spending for eye surgery has increased.)
The incentive to spend less than the recommended amount of time performing a CPT service — for which the only factors that limit billing for the service are doing it and charting it (in effect deeming it a commodity) — was recently underscored in the December 2006 issue of the New England Journal of Medicine.
2 There it was suggested that gastroenterologists who spend less than the recommended amount of time performing a colonoscopy find fewer adenomas. The minimum recommended time for a colonoscopy is 6 minutes, and the report found that gastroenterologists who spend 3 minutes doing a colonoscopy find a fraction of the number of adenomas found by gastroenterologists who spend 6 or more minutes on one.
Those who take 3 minutes undoubtedly believe they are serving their patients well, but the economics of the colonoscopy, whose reimbursement has been drifting downward, may very well explain the swift performance of the colonoscopy by some gastroenterologists.
It stands to reason that is is likewise the case that radiologists who spend 1 minute evaluating 15 11” x 17” transparencies of an MRI of the brain must be missing more than radiologists who spend 15 minutes looking at those 15 transparencies.
Experts and Neophytes Reimbursed Alike
Currently, medical fees paid by Medicare are the same for the department chairman or world-reknown expert as they are for the physician 1 day out of residency. Baseball players are paid different amounts based on their previous performance and seasoned lawyers bill at higher rates than neophyte attorneys. In medicine, this is not the case.
In fact, when Medicare was first enacted, neophytes got paid more than veterans because Medicare paid the usual and customary rate of a physician. If the department chairman at Harvard charged $300 for a service in 1964, then that is also what Medicare paid in him in 1966. Yet his fellow during 1964 and 1965 could set a fee of $2,000 for the service in 1966 when he became an attending and Medicare paid that. Payment for a service based on the usual and customary rate of a physician has gone the way of the Norman Rockwell doctor into the annals of medical history (or medical lore or myth).
In my last article on pricing medical services, I noted that independent physician associations (IPAs) often negotiate higher fees than the rack rate for their members. However, IPA’s fees are set in relationship to CMS’s fees, and IPAs’ fees will fall when CMS lowers the fees in its schedule.
So, for the time being, as a member of the Columbia Presbyterian Physician Network, I am being paid more now from Oxford and Cigna than when I was under the aegis of St. Luke’s Roosevelt Hospital. But I think — although I have not independently confirmed this — that a world expert on photobiology and photomedicine and chairman of the Department of Dermatology at Columbia and I are paid the same by Oxford and Cigna to treat PMLE. Interestingly, Aetna has a higher fee schedule for full-time staff at Columbia than for voluntary physicians who are part of the Columbia Presbyterian Physician Network.
How Will New Coding Decreases Affect Time Spent on Procedures?
We will see what effects treating medical services as RVU-defined commodities will have on dermatology now that there is a decrease in reimbursement in the 17000 series of codes for the destruction of warts, which will now be billed under 17110 and 17111, and actinic keratoses, which will still use 17004 with decreased reimbursement in 2007.
Dermatologists can bemoan these changes, but again, only a Hobson’s choice exists. The use of medical visits as loss leaders for surgical services — or, in other words, using 17004 to cross-subsidize the provision of medical care — is not an option for which the price paid for a service reified by a code is a commodity whose value must stand on its own. Unintended effects arise when medical services are interchangeable widgets whose prices are constantly bid down.
The cuts of reimbursement of 17004 will likely vastly cut into the income of pediatric dermatologists whose major procedures are the destruction of warts and molluscum.
A pediatric dermatologist told me that his gross income would fall by $60,000 if the Medicare fee cuts are replicated by commercial insurance. It is interesting to ponder that the nascent field of pediatric dermatology could be felled by a re-jiggering of 17004.
Will Commoditization of Cosmetic and Elective Procedures Occur?
The commoditization of cosmetic and elective procedures might occur. It did occur with the pricing of LASIK surgery, which was originally a procedure that commanded thousands of dollars and has now stumbled and fallen to hundreds of dollars.
If the internist of every patient offered Botox injections for glabellar lines, many of us would experience a decline in our patient base. Still, I think that the economic profits — that is profits when costs are accounted for —for cosmetic procedures will be greater than for medical services because the dermatologist has greater knowledge and power than an individual patient when deciding how much to charge, a power that is in the hands of the Centers for Medicare and Medicaid Services and the HMOs in relation to the pricing of medical services.
Although some movement has been made to pay for quality in medical care, such bonuses are usually about 10% and so far have only had a fractional effect on physicians’ incomes and practice patterns. When electronic health records become universal and the ability to monitor actions of a physician increases exponentially, this might change.
What Can We Say for Sure?
Not all dermatologists are paid the same to perform a service, yet medical services have generally been turned into commodities.
Ways to cope with these situations to maintain income and provide patient care have been developed, but the payments for medical services and the modes of the provision of medical care itself are in a state of dynamic flux.
The only sure thing that I can say is that medicine and the medical payment system will change as much in the next 40 years as they have in the first 40 years since the implementation of Medicare in 1965.
In 1964, the year before Medicare was enacted, what would you expect dermatologists to answer if asked to choose between the following two options for reimbursement:
1. the physician fee for an initial visit, or
2. the price of the medication prescribed (a tube of Hytone, 90 pills of branded erythromycin, or a syringe filled with 1.2 million units of Penicillin)?
The dermatologist would have chosen the amount of the fee for an initial visit because he would have received a greater amount of reimbursement for it.
However, in 2007, if asked this question, the same dermatologist would prefer to be paid either the cost of a tube of Taclonex, 30 pills of Solodyn, or better yet, a month’s supply of syringes of Raptiva, Enbrel, Amevive or Humira — rather than the standard fee for an initial visit.
Declining Power
The power of physicians to set prices for medical services has declined. Most physicians seeking recompense from HMOs are faced with a Hobson’s choice (no choice). They can take the HMO’s fee schedule, which implicitly deems medical services to be an interchangeable commodity, or opt out.
Dermatologists have increased their incomes (more than most other specialties) by seeing more patients in a workday mainly by hiring physician extenders to see patients and perform more cosmetic procedures.
It is unclear if the use of these compensatory strategies to maintain income will continue to work as other specialties add cosmetic services to their repertoires, a trend noted in a recent article in the New York Times detailing the extensive cosmetic, laser and Botox practice of an OB/GYN.
1 In addition, extenders (physician assistants [PAs] and nurse practitioners [NPs]) may some day have the right to provide care without a physician’s supervision, a situation already playing itself out between optometrists and ophthalmologists across the 50 states, with optometrists free in some states to perform eye examinations and some types of surgical (laser) procedures.
The pharmaceutical companies, however, have become more adroit at exercising their pricing power. They can set prices for medications covered by patents, mostly free from market competition, as unique goods rather than commodities. The pricing of drugs flows from the knowledge that most insurance plans will pay the price for a medication to which the FDA gives an indication, that is, until the medication’s patents lapse.
Even this power is eroding as insurance companies remove medications from their formularies, make patients pay more for branded medications and complicate the appeals process for the denial of a request for a medication. It is the patient who needs a medication to abate or cure a disease who faces the Hobson’s choice.
There were more than twice as many physicians per person in the United States in 2006 than there were in 1964 (to say nothing of PAs and NPs, whose occupations did not exist before 1964). The increase in the number of doctors has decreased the pricing power of each doctor. Physicians’ incomes as a percentage of per capita income in 1964 were between 600% and 700% of per capita income and are now at about 300% to 400% of per capita income. Medical services, for the most part, have become commodities by 2007. Commoditization has exerted complicated effects on the provision of medical care.
Cutting Time Spent on Procedures
Payments are made for CPT codes billed and not for the success achieved or effort involved in a physician’s intervention. The time spent providing a CPT service is supposed to relate the work of the doctor through the system of relative value units (RVU), but in actuality it is an invitation for the doctor to find ways to spend less time than the RVU estimates and thus enhance income.
A striking example of the collision of RVU and payments occurred in the mid-1980s in a hearing before Congress on Medicare fees. Representatives from the American Academy of Ophthalmology complained they were not being paid enough for performing cataract surgery, a procedure that once accounted for the most inpatient hospital days of almost any kind of surgery and is now done as an outpatient procedure. During the hearing, a Congressman asked what was a typical fee charged by ophthalmologists for cataract surgery. An ophthalmologist replied that $2,000 was the fee, on average. Then the Congressman asked how long it usually took to complete cataract surgery, and the ophthalmologist replied, “30 minutes.” This stunned the Committee.
Since that time, payment for cataracts has decreased year by year, and Medicare now pays about $350 for a cataract operation, opposing the notion that medical prices only go up. (Of course, more surgery is performed now, and the population is aging, so total spending for eye surgery has increased.)
The incentive to spend less than the recommended amount of time performing a CPT service — for which the only factors that limit billing for the service are doing it and charting it (in effect deeming it a commodity) — was recently underscored in the December 2006 issue of the New England Journal of Medicine.
2 There it was suggested that gastroenterologists who spend less than the recommended amount of time performing a colonoscopy find fewer adenomas. The minimum recommended time for a colonoscopy is 6 minutes, and the report found that gastroenterologists who spend 3 minutes doing a colonoscopy find a fraction of the number of adenomas found by gastroenterologists who spend 6 or more minutes on one.
Those who take 3 minutes undoubtedly believe they are serving their patients well, but the economics of the colonoscopy, whose reimbursement has been drifting downward, may very well explain the swift performance of the colonoscopy by some gastroenterologists.
It stands to reason that is is likewise the case that radiologists who spend 1 minute evaluating 15 11” x 17” transparencies of an MRI of the brain must be missing more than radiologists who spend 15 minutes looking at those 15 transparencies.
Experts and Neophytes Reimbursed Alike
Currently, medical fees paid by Medicare are the same for the department chairman or world-reknown expert as they are for the physician 1 day out of residency. Baseball players are paid different amounts based on their previous performance and seasoned lawyers bill at higher rates than neophyte attorneys. In medicine, this is not the case.
In fact, when Medicare was first enacted, neophytes got paid more than veterans because Medicare paid the usual and customary rate of a physician. If the department chairman at Harvard charged $300 for a service in 1964, then that is also what Medicare paid in him in 1966. Yet his fellow during 1964 and 1965 could set a fee of $2,000 for the service in 1966 when he became an attending and Medicare paid that. Payment for a service based on the usual and customary rate of a physician has gone the way of the Norman Rockwell doctor into the annals of medical history (or medical lore or myth).
In my last article on pricing medical services, I noted that independent physician associations (IPAs) often negotiate higher fees than the rack rate for their members. However, IPA’s fees are set in relationship to CMS’s fees, and IPAs’ fees will fall when CMS lowers the fees in its schedule.
So, for the time being, as a member of the Columbia Presbyterian Physician Network, I am being paid more now from Oxford and Cigna than when I was under the aegis of St. Luke’s Roosevelt Hospital. But I think — although I have not independently confirmed this — that a world expert on photobiology and photomedicine and chairman of the Department of Dermatology at Columbia and I are paid the same by Oxford and Cigna to treat PMLE. Interestingly, Aetna has a higher fee schedule for full-time staff at Columbia than for voluntary physicians who are part of the Columbia Presbyterian Physician Network.
How Will New Coding Decreases Affect Time Spent on Procedures?
We will see what effects treating medical services as RVU-defined commodities will have on dermatology now that there is a decrease in reimbursement in the 17000 series of codes for the destruction of warts, which will now be billed under 17110 and 17111, and actinic keratoses, which will still use 17004 with decreased reimbursement in 2007.
Dermatologists can bemoan these changes, but again, only a Hobson’s choice exists. The use of medical visits as loss leaders for surgical services — or, in other words, using 17004 to cross-subsidize the provision of medical care — is not an option for which the price paid for a service reified by a code is a commodity whose value must stand on its own. Unintended effects arise when medical services are interchangeable widgets whose prices are constantly bid down.
The cuts of reimbursement of 17004 will likely vastly cut into the income of pediatric dermatologists whose major procedures are the destruction of warts and molluscum.
A pediatric dermatologist told me that his gross income would fall by $60,000 if the Medicare fee cuts are replicated by commercial insurance. It is interesting to ponder that the nascent field of pediatric dermatology could be felled by a re-jiggering of 17004.
Will Commoditization of Cosmetic and Elective Procedures Occur?
The commoditization of cosmetic and elective procedures might occur. It did occur with the pricing of LASIK surgery, which was originally a procedure that commanded thousands of dollars and has now stumbled and fallen to hundreds of dollars.
If the internist of every patient offered Botox injections for glabellar lines, many of us would experience a decline in our patient base. Still, I think that the economic profits — that is profits when costs are accounted for —for cosmetic procedures will be greater than for medical services because the dermatologist has greater knowledge and power than an individual patient when deciding how much to charge, a power that is in the hands of the Centers for Medicare and Medicaid Services and the HMOs in relation to the pricing of medical services.
Although some movement has been made to pay for quality in medical care, such bonuses are usually about 10% and so far have only had a fractional effect on physicians’ incomes and practice patterns. When electronic health records become universal and the ability to monitor actions of a physician increases exponentially, this might change.
What Can We Say for Sure?
Not all dermatologists are paid the same to perform a service, yet medical services have generally been turned into commodities.
Ways to cope with these situations to maintain income and provide patient care have been developed, but the payments for medical services and the modes of the provision of medical care itself are in a state of dynamic flux.
The only sure thing that I can say is that medicine and the medical payment system will change as much in the next 40 years as they have in the first 40 years since the implementation of Medicare in 1965.
