Imagine if your bank handled all your online transactions for free but charged you only when you visited your local branch — and then kept pestering you to come in, pay money and chat with them every three months or at least once a year if you wanted to keep your accounts active.
Of course, that’s not how banks operate. There are small ongoing charges (or margins off the interest they pay you) for keeping your money and for making it possible to do almost everything from your iPhone these days. Yes, there may be additional charges for things that can’t be done without the bank’s personalized assistance, but those things happen at your request, not by the bank’s insistence.
Compare that with primary care. The bulk of our income is “patient revenue,” what patients and their insurance companies pay us for services we provide “face to face.” We may also have grants if we are Federally Qualified Health Centers, mostly meant to cover sliding fee discounts and what we call “enabling services”: care coordination, loosely speaking.
Only a small fraction of our income comes from meeting quality or compliance “targets,” and those monies only come to us after we have reached those goals; they don’t help us create the needed infrastructure to get there.
Then look at how medical providers are scheduled and paid. We all have productivity targets, RVUs (relative value units — number and complexity of visits combined) if our employer is paid that way and usually just straight visit counts in FQHCs (because all visits are reimbursed at the same rate there). Sometimes we have quality bonuses or incentives, which truthfully may be the combined result of both our own AND other staff members’ efforts.
As we are now starting to think of how to make the transition to a system that pays medical offices not for the number of visits but for the overall health of our patients (as defined by our quality metrics), we should ideally free up doctors’ time to review and act on health data that comes to us in more ways than face to face visits — but there’s a catch: We don’t think we can afford to have our docs see fewer face to face visits, because right now there is no money in what in the future will compare to the bank’s cash flow that their customers generate when they use online banking, ATMs and so on.
If a patient sends me a list of blood pressures or blood sugars, there is a cost for us to review and act on them: lost lunch breaks, unreimbursed overtime (”provider pajama time”) or lowered productivity targets (for face to face work in an organizational leap of faith that these efforts will actually result in incentive payments some time down the road).
Most medical offices are quaintly or hopelessly old fashioned in our approach to the changing demands and desires of our payers and our patients. It is hard to make the transition to something new: We are being asked to start working differently and potentially making less or spending more without knowing for sure if it will pay off.
Hans Duvefelt, also known as “A Country Doctor,” is a family physician who blogs at A Country Doctor Writes:.
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