Wednesday, August 30, 2006
Pay primary care by the hour
The physician/author, Robin Cook, explores this idea in the NY Times:As it is now, insurance companies — following Medicare’s lead — pay primary care doctors according to the number of patients they see. Each patient visit is generally reimbursed at a flat rate of slightly more than $50. The payment is the same whether the patient is a healthy, young person with a runny nose or an elderly person whose multiple chronic illnesses require many tests, referrals to specialists and detailed explanations to both the patient and his or her family.
A lawyer in general practice is not expected to accept the same low fee he gets for writing a simple will when he writes one that involves complicated business circumstances. Nor does an accountant charge the same amount for a difficult tax return as for an easy one. Why should the work of doctors be assessed this way?
A typical primary care doctor spends slightly more than half of his or her day seeing patients; the other half is spent conferring with specialists, lab technicians and patients’ families, or trying to persuade health insurance companies to cover some needed treatment. This other half of his work day must be considered pro bono. Factor in rising overhead costs (office space, employees and malpractice premiums), and the situation easily becomes untenable.
Posted by Kevin |
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I have worked in a hospital-owned practice on a salary and in an "eat what you kill" (I know it is a bad term) practice setting where I am part owner. I am definitely more motivated in the latter environment to be efficient and productive. I really don't think this is the answer to problems. Personally I think that P4P may be a boon for PCPs as it puts the cost-control of the entire system in their lap and rewards them for keeping cost down and quality up. Yes, I know...In theory.
"Dr." Robin Cook is a full time writer who essentially created the genre of "medical thriller" in 1977 with Coma. The only thing he has in common with modern practicing primary care physicians is that he once went to medical school. In fact, the article quoted begins by referencing a "friend of mine from residency 30 years ago."
He has no idea what he's talking about, and I hope the AAFP takes him to task for his ridiculous comments. For example, it is lawyers who charge by the hour (hence the larger bill for the more complex case) whereas the idea that physicians are reimbursed at a flat rate is outrageous! Where did he get that idea?
Oh yeah. He writes fiction.
He has no idea what he's talking about, and I hope the AAFP takes him to task for his ridiculous comments. For example, it is lawyers who charge by the hour (hence the larger bill for the more complex case) whereas the idea that physicians are reimbursed at a flat rate is outrageous! Where did he get that idea?
Oh yeah. He writes fiction.
Personally I think that P4P may be a boon for PCPs as it puts the cost-control of the entire system in their lap and rewards them for keeping cost down and quality up.
How does it keep the cost down? Does P4P penalize doctors for defensive testing?
How does it keep the cost down? Does P4P penalize doctors for defensive testing?
# posted by 
: 7:45 PM
: 7:45 PM
If you reward good medicine (rather than bad) you avoid misuse of resources rather than encourage it. If diabetics are well cared-for, they will not go to the hospital as much. If cholesterol gets managed better (and attention to it is made at the PCP level) then they will go to the cardiologist less. If colonoscopy is done routinely, colon cancer will be mainly found as polyps and not end up in chemo, etc. The whole idea of "an ounce of prevention" bears a lot of truth. Our current system pays more for little thought and less for deeper thought. I don't currently get rewarded financially for making sure a diabetic has gotten all the care I need. But if I don't take the time, both the diabetic and the whole system ends up paying for my lack of attention. The whole idea of P4P is to reward those who are way upstream and can do the littler things and prevent the bigger things from happening.
Make sense?
Make sense?
I am pretty much exclusively talking about primary care. Here is a quote from the New England Journal:
Serious effort is required to develop a national primary care payment policy. Public policy on primary care does not exist; the fortunes of primary care are dictated not by the health care needs of the country but by a specialty-rich, quantity-based reimbursement system. Few legislators, particularly among those responsible for the trend-setting Medicare program, are aware that primary care is struggling. An educational campaign is needed — to explain the nature and causes of the threats to primary care's survival; to provide well-documented information on the benefits of primary care, focusing on the potential for a strong primary care–based system to control health expenditures; and to offer concrete proposals for reforming both primary care at the microsystem level and the payment scheme at the macrosystem level.
Who might support a national policy to rescue primary care? Employers and insurers, public and private, may reap a return on investment by fostering a more effective primary care sector that will reduce health care costs. The public would benefit from microsystem improvement, with fewer appointment delays, higher quality, and more meaningful interpersonal relationships. Even specialists might recognize that they would suffer if primary care deteriorates, being forced to coordinate care and confront psychosocial issues in patients with multiple acute and chronic conditions rather than focusing on diagnosing and managing specific diseases within their scope of expertise. Whoever takes up the cause of primary care, one thing is clear: action is needed to calm the brewing storm before the levees break.
The basic assumption is that primary care saves money if done well. The problem is that the current payment system does not work for primary care, for which they recommend P4P.
My point exactly.
Serious effort is required to develop a national primary care payment policy. Public policy on primary care does not exist; the fortunes of primary care are dictated not by the health care needs of the country but by a specialty-rich, quantity-based reimbursement system. Few legislators, particularly among those responsible for the trend-setting Medicare program, are aware that primary care is struggling. An educational campaign is needed — to explain the nature and causes of the threats to primary care's survival; to provide well-documented information on the benefits of primary care, focusing on the potential for a strong primary care–based system to control health expenditures; and to offer concrete proposals for reforming both primary care at the microsystem level and the payment scheme at the macrosystem level.
Who might support a national policy to rescue primary care? Employers and insurers, public and private, may reap a return on investment by fostering a more effective primary care sector that will reduce health care costs. The public would benefit from microsystem improvement, with fewer appointment delays, higher quality, and more meaningful interpersonal relationships. Even specialists might recognize that they would suffer if primary care deteriorates, being forced to coordinate care and confront psychosocial issues in patients with multiple acute and chronic conditions rather than focusing on diagnosing and managing specific diseases within their scope of expertise. Whoever takes up the cause of primary care, one thing is clear: action is needed to calm the brewing storm before the levees break.
The basic assumption is that primary care saves money if done well. The problem is that the current payment system does not work for primary care, for which they recommend P4P.
My point exactly.
If cholesterol gets managed better (and attention to it is made at the PCP level) then they will go to the cardiologist less. If colonoscopy is done routinely, colon cancer will be mainly found as polyps and not end up in chemo, etc.
You are forgetting that in these examples a hundred or a thousand need to be treated/tested for one to benefit (or for money to be saved on one person). You only see this one person who benefits (and potentially saves money), but you are forgetting about everyone who'd never have gotten heart desease or cancer even without statins or tests yet get treated and tested. You are also forgetting that some of the heart attacks are instantly fatal - like the one that killed my brother-in-law: he could have benefitted from statins and blood pressure medication (he had high blood pressure and was obese) if he had bothered to go to a doctor - he hadn't seen one in 5 years before his heart attack. So instead he suddenly fell at the age of 56 and was dead when the ambulance arrived. And saved healthcare money.
If people with only 1% probability of a heart attack in 10 years take statins (easily happens with current guidelines), would the amount saved on this one person be greater than the amount spent on everyone? What if some of them have side effects? What if this one who benefits ends up having a heart attack later or suffers from some other condition at the end of his life that is more expensive?
As far as screening is concerned, have you ever wondered why in some cases insurance companies had to be forced to pay for it? They only care about the bottom line not who lives or dies, and they have done the calculations. Same with countries with national health systems - they do less screening than the US, not more. The amount saved on 1 person out of a thousand is not always greater than the amount spent on screening everyone, investigating false positives, and in some cases like mammograms and PSA - treating more people because of overdiagnosis.
Add to it that what is true today ends up wrong tomorrow. 6 years ago, someone could've added HRT for symptomless women for heart desease prevention. Then came WHI.
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You are forgetting that in these examples a hundred or a thousand need to be treated/tested for one to benefit (or for money to be saved on one person). You only see this one person who benefits (and potentially saves money), but you are forgetting about everyone who'd never have gotten heart desease or cancer even without statins or tests yet get treated and tested. You are also forgetting that some of the heart attacks are instantly fatal - like the one that killed my brother-in-law: he could have benefitted from statins and blood pressure medication (he had high blood pressure and was obese) if he had bothered to go to a doctor - he hadn't seen one in 5 years before his heart attack. So instead he suddenly fell at the age of 56 and was dead when the ambulance arrived. And saved healthcare money.
If people with only 1% probability of a heart attack in 10 years take statins (easily happens with current guidelines), would the amount saved on this one person be greater than the amount spent on everyone? What if some of them have side effects? What if this one who benefits ends up having a heart attack later or suffers from some other condition at the end of his life that is more expensive?
As far as screening is concerned, have you ever wondered why in some cases insurance companies had to be forced to pay for it? They only care about the bottom line not who lives or dies, and they have done the calculations. Same with countries with national health systems - they do less screening than the US, not more. The amount saved on 1 person out of a thousand is not always greater than the amount spent on screening everyone, investigating false positives, and in some cases like mammograms and PSA - treating more people because of overdiagnosis.
Add to it that what is true today ends up wrong tomorrow. 6 years ago, someone could've added HRT for symptomless women for heart desease prevention. Then came WHI.
# posted by : 11:02 AM
: 11:02 AM
