Better care is primary

Medicare, the largest single payer of healthcare services in the country, inadvertently encourages uncoordinated, excessive care. In 1992 Congress established a physician payment system intended to limit costs, but the federal government gave advisory authority to a committee weighted in specialists’ favor. This committee offers payment recommendations for more than 7,000 different procedures, and the more physicians do, the more money they make.

To improve primary care, the federal government wants to add a management fee to the usual visit payment. An informal coalition of primary care providers favors an approach that does away with piecemeal reimbursement, which has led to rushed visits, reduced access, unhappy patients and demoralized physicians. The coalition is trying to get insurers in Massachusetts interested in a "Medical Home" model, in which primary-care practices would receive a comprehensive payment in return for high-quality, patient-friendly care.

So what does this mean overall?

This sounds a bit like the old managed care model, which physicians and patients decried in the 1990s for its inadequate payments and frequent denials of care. However, the coalition would make the payments higher and adjust them depending on how medically needy the patients are and how well the practice achieves good results. Last month the Capital District Physicians’ Health Plan, in Albany, announced a two-year trial in which they will implement the comprehensive payment plan.

This is actually a modification of the Medical Home which Dr. Alan Goroll has championed.  Here is his model thoroughly described – Fundamental Reform of Payment for Adult Primary Care: Comprehensive Payment for Comprehensive Care.

Under the authors’ new model, practices would receive monthly payments for each patient under their care, with adjustments made according to the patient’s needs and risks. Over two-thirds of the payments would be designated to pay for multidisciplinary health care teams (e.g., nurse practitioners, nutritionists, and social workers) and for information systems to monitor safety and quality, including interoperable electronic health records. Fifteen to 25 percent of payments would be linked to performance in meeting benchmarks of cost-effectiveness, efficiency, health outcomes, and patient-centered care.

Payments for hospital and specialist services, laboratory tests, imaging studies, and other ancillary services would remain unchanged and continue to be paid under the resource-based relative-value scale system. Appropriate use of such services would be promoted through reliance on evidence-based guidelines and performance incentives linked to efficiency.

This is another medical home variation.  I am delighted that the leaders of this model have found places to try the model.  In 2008, we need a variety of models tried to improve primary care provision, and make the field more attractive to students and internal medicine residents.  Bravo!

Related posts:

1. Dazed and Confused – Levels of primary care?
2. Primary care payment – is win-win possible?
3. Primary care – money is the answer
4. Universal health care will require fair pay for primary care
5. Are retainer practices the model for PCMH?

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