Pay for Performance an Insult to Profession

I have read the “Washington Report” column by Ronald Szabat, J.D., LL.M., in the August 2005 ASA NEWSLETTER.

Am I the only physician who finds the idea of a carrot-and-stick approach to reimbursement abhorrent? As a physician, I find it insulting that Medicare and organized medicine would seem to go along with the idea that we need to be somehow financially encouraged to provide quality medical care and discouraged with financial penalties for providing substandard medical care.

Most physicians, including myself, provide excellent medical care to our patients because it is our ethical responsibility as physicians to do so. We provide the same excellent care to our self-pay patients as we do to our commercially insured patients regardless of the reimbursement.

Do physicians not see that this is simply another ploy on the part of government to ratchet down reimbursement under the rubric of promoting quality medical care?

There is not going to be any additional money added to Medicare for this. Medicare is already a bankrupt system with multiple unfunded mandates. The government continues to pile on more mandates for spending without any significant increase in revenue. We should return to a system where patients pay us directly for the medical care we provide and value the services we render to them.

Pay for performance, dear physicians, means only one thing: We ultimately will be paid less and less for the medical services we render.

We will continue to see efforts to reduce Medicare reimbursements under a variety of different guises. Never mind the fact that no one has actually done a large-scale, double-blinded study to prove that the pay-for-performance concept even works. The same goals of improved care could be accomplished swiftly and at less cost by better educating physicians rather than treating us as though we are Pavlovian dogs, salivating to the sound of a bell.

Pay for performance should not be implemented “carefully, slowly and fairly.”

It should not be implemented at all. All of organized medicine needs to take a firm stand against this proposal now.

Lee A. Balaklaw, M.D.
Louisa, Kentucky

MRI Procedures Truly a Team Effort

I read the letter to the editor “Rethinking Anesthesia Care During MRI” in the May 2005 ASA NEWSLETTER by Paul M. Kempen, M.D., Ph.D. His statistics at a California refresher course were appalling [that of those he polled, no provider remained in the scanner room with the patient]. I am now retired, but from 1989 to 1996, I administered — along with a nurse anesthetist (usually the same one) — most of the anesthetics for MRI at a large Midwestern teaching hospital. One of these was even for a 34-year-old fully grown, rather small, silverback lowland gorilla. This was the most fascinating anesthetic I ever administered.

This was a full-sized adult 1.5 Tesla scanner operating at full power. We always administered these anesthetics while remaining inside the scanner room. One of the reasons for this, besides being the proper way to monitor the patient, was because of a very close relationship with the MRI technicians. They allowed us to take a standard anesthesia machine inside the scanner but outlined the limits, and we meticulously obeyed these limits. Once we figured out which infusion pump would work within the scanner, we used it. This was easier than being the infusion pump with a handheld syringe, which I had done. We also monitored pulse oxymetry and capnography along with EKG and BP.

There is a definite learning curve for administering anesthesia for MRI, and I suggest that this not be given to the youngest or least experienced anesthesiologist but to a team that does most of these all the time. Also we as anesthesiologists need to provide a good working environment for the MRI technicians so that we both work in harmony for the benefit of the patient.

This same team administered multiple anesthetics for children for radiation therapy. We could not stay next to the patient here but did go behind the radiation shield with the technician for the short administration of the radiation. We administered as many as 75 anesthetics to the same patient, some twice a day. Again, the cooperation with the radiation therapy team was most helpful. Seeing the same anesthesia team for most every anesthetic was very reassuring for the patient and parents.

Bernard C. De Leo, M.D.
Sun City Center, Florida