Fixing health care – payment redux

Thanks to all the comments on my previous post.  I believe that I did an incomplete job in describing my concerns.

Our current payment system has incentives for the wrong behavior.  If all lawyers received $200 for a will (fixed price, regardless of complexity), we would see shoddy, cookie cutter wills and lawyers who avoid complex elderly rich people.  You can repeat that sentence for tax accountants.

When you see any professional or craftsman, you pay according to complexity.  Complexity includes a breadth of issues.  In medicine it certainly should include the number of chronic diseases, the severity of those diseases, the number of medications, whether the patient has had a recent hospitalization, the age, comorbid psychiatric diagnoses and whether or not the patient has one or more new problems.

Medicare (and thus private insurers) pay us for a visit.  They provide a modest increase for increased complexity, but then require irrelevant documentation procedures.  They do not pay us for non-office followups – telephone calls, emails, or even text messaging.  Try that with your lawyer.  The lawyer tells you a joke, and you pay for another 6 minutes of their time!

We need a true payment system that allows physicians to more easily bill for their time (they have a clumsy, difficult to document mechanism.)  We need the ability to increase our rates if the demand for our services is great.

Retainer medicine provides a model which we could modify to develop a more reasonable payment structure.  We need to decrease the physician’s overhead.  We need to decrease the bureaucracy of payment.

Will better payment make a difference?  I assert that better payment is the only driving force which will direct students and residents to “primary care” (readers know that I actually hate using this term because it is so poorly understood.)  By primary care, I refer to comprehensiveness, continuity,  and accessibility.  We need more true primary care physicians.  Only when we fix payment can we increase these numbers.