Fixing health care – payment schemes and standardization

There is a lot of talk, as there should be, about fixing health care. Two articles in the NY Times this week discuss this – one describes a bad idea and the other a good one.

The first, (NY Times 4/29/2010) reports on a article just published in the New England Journal of Medicine on the work primary care physicians do.  First, they describe their pay …

Family doctors are paid mainly for each visit by patients to their offices, typically about $70 a visit. In the practice in Philadelphia covered by the study, each full-time doctor had an average of 18 patient visits a day.

Next they describe the work they do…

But each doctor also made 24 telephone calls a day to patients, specialists and others. And every day, each doctor wrote 12 drug prescriptions, read 20 laboratory reports, examined 14 consultation reports from specialists, reviewed 11 X-ray and other imaging reports, and wrote and sent 17 e-mail messages interpreting test results, consulting with other doctors or advising patients.

And now the interesting part…

The study, medical experts say, also suggests the direction of changes needed if family practices are to flourish and more effectively improve the health of patients and contain costs. It starts, they say, with compensating doctors for work other than patient visits.

Along those lines, from the article itself …

our internal compensation system now recognizes telephone calls and e-mails as part of our productivity metric.

In other words, the argument is (i) to care for patients physicians must do much more than just visit with them, (ii) these non-compensated tasks are providing a burden and so (iii) we should consider paying them for those tasks …

At a time when the primary care system is collapsing and U.S. medical-school graduates are avoiding the field, it is urgent that we understand the actual work of primary care and find ways to support it. Our snapshot reveals both the magnitude of the challenge and the need for radical change in practice design and payment structure.

I realize that we need many ideas to fix health care, but this one doesn’t hold water. It may be unfair to characterize the idea as “payment for emails” but that is the spirit of their pitch. As an educator I can sympathize with their woes  – nobody pays me extra to email with students! What a wonderful world that would be… If I were paid to email students, then I could figure out how to write a macro so that my computer sends out emails every five minutes to every student. Cha-Ching! But that is my point – if you can’t monitor quality, you shouldn’t pay for a tasks.  Unless we have people checking that the physicians are sending out legit emails and phone calls, it  doesn’t work to pay them for those tasks. So in the end, if the goal is to make primary care more attractive to medical students, then paying more than $70 per visit may be the better approach. But that just looks like paying physicians more, and so nobody will write that up in the NY Times.

The second article (NY Times 4/30/2010) discusses the aggravation physicians deal with when trying to figure out how to get paid for the care they provide their patients. The problem is that patients have different health care insurers and each insurer has its own complicated policies for what will and what won’t be covered. This leads to lots of confusion and frustration:

With each plan permutation, it becomes more and more difficult for a doctor to know how to provide care that will work with a patient’s particular coverage. One of the doctors who was surveyed in the Health Affairs study wrote: “It’s like going to the gas station to gas up your car and having to change the nozzle on the gas pump because you have a Toyota and the pump was made to fit Fords.”

So why don’t we have gas pumps dedicated to specific vehicles? Because no vehicle manufacturer could gain a competitive advantage by doing so. Whatever benefit of exclusivity would be small compared to the inconvenience it would impose on consumers. But health insurance companies seem to think differently. They appear to view their tangled mess of quasi-infinitely varying coverage plans as a source of competitive advantage. Nevertheless, it seems substantial value would be created by forming a standardized delivery means for these plans. McDonald’s and many other firms understand the value of process standardization and it would be interesting to explore whether this idea could benefit health care. It is disappointing that this idea seems to be absent from the national debate on health care reform

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One Response to Fixing health care – payment schemes and standardization

  1. There is an increased risk of recurring gestational diabetes in pregnant women who developed gestational diabetes during their first and second pregnancies, according to a Kaiser Permanente study appearing online in the American Journal of Obstetrics and Gynecology.

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