Fork You by Pat Conrad MD


In the movie “Heartbreak Ridge”, Clint Eastwood plays a grizzled Marine gunnery sergeant whose maxim is “Improvise, adapt, and overcome!” After his superior horribly bungles an alert drill, the commanding general bypasses the incompetent officer and asks the sergeant for his assessment. The incomparable answer: “Cluster-goat, sir!” Only he didn’t say goat.

The latest Family Practice News has a little back page article (silly migraine and fatty liver stuff on the front page), “In post-SGT era, physicians face two payment options.” The American College of Physicians mouthpiece stated, “There’s going to be a fork in the road…Physicians will have to choose one of two paths, you can’t do both.” But no, on selection the physician is not locked into either model and may change year to year. So you can revisit, and be turned by the same fork again and again until done?

  • Option 1: Merit-based incentive payment system (MIPS). This is similar to current Medicare fee-for-service, except the physician will have to meet performance metrics or take a penalty. Yay, meaningful use. Docs in the MIPS are compared to their peers, and will be eligible for additional incentive pay if they are in the top 25th percentile. Which is the state paying its agents to fight each other, the moral equivalent of the gladiator industry.
  • Option 2: Alternative-payment model (APM). This is a higher risk/reward route, wherein the doctor gets a guaranteed 5% increase yearly for 6 years, BUT “within the construct of an ACO.” Docs who don’t make the ACO cut will not be “rewarded with their shared savings.”

The incoming president of the ACP, Dr. Nitin Damle, has secured his lapdog status by promising “significant improvement in the quality of care and improved reimbursement.”

There will be no improvisation, adaptation, or overcoming. It’s all cluster-goat.

Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  2 comments for “Fork You by Pat Conrad MD

  1. Perry
    June 8, 2015 at 9:49 am

    Once again our illustrious associations, the AMA, AAFP and the like have locked us into the penitentiary of the government’s idea of healthcare. Reading the comments on that article in FP News, AAFP News Now and Medscape, I think when I reach Medicare age in another 7 years, I will have trouble finding a doc.
    At that point, maybe it’s time to take up drinking, smoking, and eating lots of red meat to hasten my demise.

  2. Steve O'
    June 8, 2015 at 9:19 am

    The underlying myth to this story is that competition produces quality. This is a childish view of business, a distortion of the concept of free-market economics. Jack Welch’s dangerous and dicey idea of maximizing employee turnover – “fire the least productive” – sounds credible in the sound byte, but is absurd in many situations.
    We have the “social evolution” theory of a hundred years ago, come back to medicine. If you apply a threatening force to a class of individuals, mindlessly and without genuine goals, the pretense is that they will somehow self-assemble into a “better group” more capable to resist the force. Those who can, will; and those who cannot, will be ground down.
    “Crushing the incompetent” has no basis in medicine – not on the front lines. Absurd and intangible penalties and goals do not work magically to sort out the “best” and “worst” providers. Humans, after all, tend to be astute in their perception of the hypocritical and futile. In such situations, they are not “energized,” or even selected for – they learn how to avoid the lash and survive the oppression.
    “Crushing the incompetent” only goes so far, not to the top. Those who impose insane and unproductive rules on the ones that actually DO the JOB, could care less if they are any good at rulemaking and task-achieving. They do not show competence, rather they ooze contempt. “No extra scrap of bread for you, worker bee! That should teach you a lesson!”
    In the humiliating days of racial ignorance in this country – days which may not be over, you might ask – the “modern pressures” applied to lesser races were considered benign, if not actually helpful – they “helped” the backward races evolve quickly to overcome their innate deficiencies. The attitude of contempt has never changed much – what has changed is the social skill of doublespeak, SAYING this in bland terms although still MEANING it in practice.
    Doctors now seem to need “help” in understanding their deficiencies – fear of technology, superstitious worship of their position, complete inability to comprehend the simplest fundamentals of capitalism. They must be forced into right thinking, and those who cannot keep up and adapt will fall by the wayside.
    Applied to practical situations, it is transparently psychotic. Perhaps slavery in America was not merely neutral, but benevolent, they thought – it helped the Black race evolve to a level of higher advancement! When they advanced sufficiently, slavery fell by the wayside – it became obsolete. Imagine that! Jim Crow, perhaps, was a force for Black advancement; it helped ‘them’ strive to improve ‘themselves,’ the comfortable assured themselves.
    The pretense is that arbitrary and oppressive treatment merely helps the subject advance to the best of their abilities. It was the “Organic Chemistry” principle in medical training, writ large on a societal level. The meaner the drill sergeant, the better the recruit; the harsher the husband, the more obedient the wife.
    If one reads and hears true American thinkers, from Jefferson and the founders to Reverend Martin Luther King, one considers that the intent this country was to release those cruel and primitive prejudices of millennia past. They not only shackle the slave, but the slavemaster as well. The thought that people flourish on their own merit and display their own abilities WITHOUT being beaten, was a principle found, and often forgotten, in our culture.
    One can spurn ignorance – but never be immunized against it. And here, in this way, it has come back – that insufficient arbitrariness and cruelty leads to selfishness and laziness. That is the turn we have taken in medicine – and a backwards turn at that, and we accelerate – back through the centuries in leaps and bounds.
    That is the voice of the doctors who oppose this harsh oppressiveness – not merely because it hurts them individually, but it goes against the mission of the profession. The bell tolls not only for the physician, not by the least – it tolls for all of us.

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