Fixing health care - focus on payment
Fixing health care February 25th. 2008, 3:24pmChoose a lawyer to develop your will. You can find differing quality and experience, and your bill will reflect that experience. Go to an experienced lawyer, and you pay more, and it well may be worth it.
Choose an accountant for your business. You pay more for a more experienced accountant. Usually you benefit from the increased skill.
Buy a Yugo or an Audi. The Audi will cost more, and be worth it.
Eat at McDonald’s or a 4 star restaurant. You get the point.
Go to an internist with 20 years experience, or one who just graduated from residency. They get paid the same regardless of their experience, or how much time they spend with you and considering your problems.
Does this make any sense? When I see you in the office or the hospital, I receive a payment based on a billing code. I cannot charge you for emails, or telephone calls, or reviewing your old records, or discussing your problem with a colleague.
How we pay physicians creates problems. We have a totally irrational payment structure, which discourages thinking and encourages doing. We have a payment structure which drives physicians towards speed and away from careful consideration.
Unless we recognize the importance of the payment system and revamp that system, we will continue to get what we pay for - quick, incomplete visits - too many procedures - unwillingness of physicians to communicate with emails and phone calls. And just remember not to blame the physicians. They are making economically rational decisions. If you design payment as Medicare has, you will reap the weak seeds that you have sown.
February 26th, 2008 at 8:02 am
DB,
Health Affairs Blog has had a nice series, pretty wonkish, regarding the payment system as set by Medicare. They address the problems, offer some suggestions for change, and talk about what may be coming down the pipeline. The whole series is worth a read, but I found this entry particularly interesting, RE: the CHAMP act.
http://healthaffairs.org/blog/2008/02/21/the-%e2%80%9cdoc-fix%e2%80%9d-the-champ-act-approach-to-medicare-physician-payment-reform/
Gives some sense of where we might be heading.
February 26th, 2008 at 9:11 am
Another thing that is wrong with the current situation is that (at least with our insurance) we never see the bills and have no clue how much is being paid to the doctor on our behalf). I only found out what 2 doctors were charging when the insurance company erroneously refused several claims - and I must make clear that we only know what the doctor was charging, not what s/he accepted….
February 26th, 2008 at 11:19 am
Actually, paying more does not always generate a superior outcome. Take the schools in the District of Columbia, or many other city systems. Taxpayers pay plenty for those schools, which have very high per pupil costs, and they deliver little.
I agree that health payment systems are crazy, but I am not sure that MORE money is the answer. I think focusing on bang per buck might be as successful.
I’d say that agrees with your notion that thinking should be paid for at the same or superior rates to doing. But I do not think that the focus on payments alone will get us what we want or need.
February 26th, 2008 at 8:28 pm
“Taxpayers pay plenty for those schools, which have very high per pupil costs, and they deliver little.”
This is a poor example, because the providers in the school state system are teachers who get paid the same whether they do a good job or a bad one. With physicians, we are talking about private enterprise.
February 28th, 2008 at 8:01 am
Actually, we really aren’t talking about private enterprise when it comes to physician payments–that’s the point. Because of the way the government pays doctors for Medicare and Medicaid patients, you make the same amount whether you do a good or poor job. In fact, I would say you make more if you “churn” patients–handle just 1-2 problems per visit and make them come to see you more frequently, then if you do what patients would like, which is to handle a number of problems at a single visit. I think the former is inferior care, but MDs who do that well make more money. Moreover, if we go to some type of single-payer system, or expand Medicare to cover the entire population, like some people seem to want, this situation will worsen. Already doctors often don’t do what patients want, because it isn’t in their financial interest to do so. Patients want doctors to spend time, explain things, order the tests and prescribe medications according to the patient’s preferences, and they would like phonecalls returned and their care coordinated with specialists, etc. It is NOT in a physician’s financial interest to do most of this, because it is not paid for, in fact the doctor has an incentive NOT to do these things because he needs to do the things that pay. It’s a sorry state of affairs and I don’t think it will get better until patients and doctors revolt.