A Method For Generating Good Outcomes through Correct Incentives in the Medical System

Would not the natural solution to paying doctors a ton of money and treating them like crap be to pay them less and treat them better?

You’d think so but no.

“Treat them better” means “work them less individually.”
“Work them less individually” means “hire more individuals to maintain the amount of work being done.”
“Hire more individuals” means “pay them more.” (This line is false in an interesting fashion)

If you need the same work done in less time, you need more people. That should be completely obvious. If you lower the pay, you’ll get fewer people. That part should also be obvious.

And yet you’re completely right, but your focus is in the wrong place. You can hire more people for less pay – if they’re less qualified. This is the correct decision. Since I love to harp on the Danish GP, I will do it some more. The archetypical GP’s Clinic has one GP and one secretary plus contracted cleaning services (There is not enough that needs cleaning to hire full-time cleaning staff) and one part-time nurse. In the most well-run GP’s Clinic I am familiar with, five GPs have [old data now] a service staff of: Three secretaries, six or seven nurses, three or four lab assistants and I believe four full-time cleaning staff. Due to various efficiencies they have found, the Clinic can handle a volume of patients as if each of those various staff members counted as 3/4th of a doctor each – because ¾ths of what a GP does actually does not need you to be a trained GP but can be handed off to others.

There are so many things that you really shouldn’t use doctors for – or nurses for that matter – wastes of the precious resource that is their time. Every minute a doctor wastes is a minute more the doctor must be at work to do doctorial duties. I’ll quote from the comments on @slatestarscratchpad ‘s blog:

Junior doctors in Ireland (and presumably the UK) spend most of their time doing routine jobs that are handled by nurses or phlebotomists in almost every other civilized country. This includes recording ECGs, inserting venous lines, taking arterial blood gas samples and giving the first injection of any newly prescribed intravenous antibiotic. They also have to do a lot of stuff that should be handled by non-medical staff, such as tracking down old X-rays or old handwritten patient records. (It is possible that they have since moved into the 21st century and digitalized this, but if so this happened during the last 4-5 years).

I’ll interpret “most of their time” as if it means “at least half”

Hire non-doctors to do this work and you can cut doctor shift length in half.

I suspect a lot of the problem is status games. A Junior Doctor is not yet high enough in the game to have a personal secretary, no matter how much of an economic benefit this would be in the “tracking down old X-rays” department. You get some of the same nonsense in software development and engineering – I have yet to work for any company, neither when Salaried nor as a Consultant, where my work efficiency could not have been well increased with a part-time secretary – or possibly better, a single full-time secretary for each four developers/engineers. But secretaries are status symbols for management, so none of that.

I recall especially an office I worked in once as a consultant. The manager had twenty employees under him, all engineers, and zero secretaries (because this department was not so important.) It was the number one improvement I suggested to him, but he couldn’t get away with it. Spend two hours of a senior engineers time to courier a folder to elsewhere? Absolutely – the folder has to get there and engineers are all we have. Secretary? Not on your life.

And this brings me back to the Five-man GP team. No paperwork above, nobody else responsible for their decisions

Non est salvatori salvator,
neque defensori dominus,
nec pater nec mater,
nihil supernum.

They’ve hired the appropriate number of secretaries. And nurses. And lab assistants. And they are, the five of them, making more money than God but they have, by God, earned it.

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