Fixing health care - payment redux
Fitness and weight loss February 28th. 2008, 8:52amThanks 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.
February 28th, 2008 at 10:34 am
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.
A single-payer system will certainly reduce overhead and bureaucracy. As long as we continue to have a health insurance system where profit is maximized instead of effective care, Dr. Center, we’ll continue to have a system with pre-existing conditions, coverage caps, fighting for medication and treatment approvals, etc. The way insurers make money is by getting rid of sick people, insuring healthy people, and denying care. And all of those things demand bureaucracy.
February 28th, 2008 at 10:35 am
Dr. CentOr! Typo, sorry!
February 28th, 2008 at 10:53 am
graham, Medicare is single payer for the elderly. Do you believe a primary care doctor could survive on medicare alone? If you do, you are living in a fantasy world. Medicare payment structures, through their attempts to reign in costs from a payment containment model, instead of a demand model has given us the over doctored, over proceduralized health care we have today.
Having everyone on Medicare will not only increase costs to the system, it will decrease payment to physicians AND as a result, will only exacerbate the issue with volume.
A third party payer by any means, government or private, will result in the same outcome. Higher cost care without a significant benefit in health.
Put the people in control of their health care spending with their own dollars, and you will see the demand curve shift down ward.
Get the physician out of the position of being the insurance companies float, and you will see the cost structure plummet.
There by increasing access to care.
March 1st, 2008 at 10:33 pm
I do not think it follows that a single-payer system automatically means less overhead and bureaucracy. I worked in the VA for 9 years–and there was plenty of both! Moreover, there was no “reward” to any VA provider for doing a good job for patients (however you define it).
Single-payer advocates like to say that the “single payer” needn’t be the government, but some other (third) party. Well, who might that be? And does it matter who it is? If the funding is through taxes, then the government holds the purse-strings (and pushes the levers and controls healthcare delivery).
Our system is crummy because the profit motive is not checked by feedback from consumers–patients don’t have the ability to shop around for doctors, based on readily available outcomes information, and obtain the care they value most and are willing to pay for. Right now, “effective care” is being determined by insurance companies and the government, not a doctor and her patient in a mutual discussion. How would the latter be facilitated with a single-payer system? I just don’t see it.
I can’t tell you how many patients would like me to call them for lots of things, and email them, etc. They want the sort of attention I’d like to provide, but I can’t because of the way I have to work to get paid. I believe the retainer method is the closest thing to getting back to what should matter–the doctor-patient relationship.
March 4th, 2008 at 5:04 am
i agree totally.