Massachusetts looks to eradicate fee-for-service care
We’ve talked about fee-for-service healthcare as being one of the the many current practices in need of reform, according to the Boston Globe, Massachusetts will be the first state to attempt to roll with it. The proposal will replace current compensation protocol with a global payment, where care will be issued by a network of doctors who will be rewarded for keeping their patients healthy.
The drastic restructuring of why and how doctors get paid has to be addressed, but doctors are not the only issue. All the rooms in the house need a good sweeping.
Throughout this process I have dealt with doctors, both women and men, old and young; no surprises they are like the rest of us. Some are fantastic at their jobs and some are ok, some have motivations that leave room for questioning, some are beacons of ethical practice. I presume the rest of the human-run health industry is not all that much different. For every doctor that takes advantage of the system, there is a health insurance CEO doing the same. For all the lawyer who defends a patient legitimately harmed by the system, there are those few chasing ambulances. Humans are imperfect—at times with self-indulgent, profiteering tendencies—and so are the systems they design. The key is cleaning out all rooms of the house, and applying a progressive treatment to eliminate (and strongly discourage) the grimier of motivations.
That is going to take time and individuals who are willing to make compromises. For now, there are less legislative heavy reform measures the system can start to work on. Spending my last three weeks in and out of the hospital and clinic, I am awed by the amount of useless paperwork and overhead. And then there is the paperwork from the insurance companies. Flip no further than this week’s issue of The Economist, where a disgruntled reader, writes:
“Look into the front offices of doctor’s premises and hospitals, you will see an army of clerks and accountants dealing with a multitiude of insurance companies, each with different forms, different criteria and different payment schedules. If we would be able to standardize medical forms we would be able to absorb the cost of covering the uninsured..”
That may be a bit bold but the point is well taken. Health insurance forms and verifications take too much time, are too confusing—often purposefully so later down the road insurers can deny claims. During the past six months working for a doctor, I watched the office manager and secretaries spend countless hours tied up in mounds of faxes and phone calls verfiying insurance. Getting through the stuff is a full-time job and any doctor who wants to keep his business afloat needs hired help to handle it. The whole thing becomes about money; doctors devising how to get reimbursed and insurance companies figuring out how not to pay. Meanwhile your sitting in the waiting room, reading your third magazine.
And the bigger the practice, or clinic the more man power is needed. Two weeks ago, in one boxy exam room, my mother, my father and I pow-wowed with two financial advisers (both with forms in hand), a case manager and a care coordinator(what the hell is the difference), a social service worker, and the doctor–who could forget her. All were being paid, most were accomplishing little. Instead of one or two highly competent employees knowing a patient’s case in and out, three, four or five know the case sort of well and have to have two or three meetings to get on point. It all cost money, too much money.
The details of the Massachusetts plan haven’t totally rolled out and as the report noted, the devil remains in the details. I hope that Mass. reformers have not been so short-sighted to see this costly crisis as a direct result of only fee-for-service care, other adjustments need to be made—in tort reform, by insurance companies and across a system collaspsing under the weight of its’ own excess.
August 5th, 2009 at 11:01 am
Global capitation as it is described in the article is not a new idea. As a physician in Massachusetts for the past 18 years I have seen several health care plans in the 1990s attempt to use this model. Secure Horizons was a senior program which took the place the Medicare and promised the preventive care to its enrollees. What was not disclosed to do patients is that the doctor had a strong financial disincentive to withhold referrals, expensive prescriptions, skilled nursing facility care and hospital care.
As I heard it described to me by a Kaiser Permanente physicians/salesman. “If you make a referral for Mrs. Jones to the dermatologist, consider it like you reached into your back pocket, took out your wallet and stapled a $100 bill to that referral form.” After all, with global capitation the primary care physician keeps any leftover funds as his fee.
After many patients found out about this perverse of for incentive the program finally died out.
Imagine having to beg your primary care physician for the care you think you need. Some patients would even feel guilty about asking for referrals because they new it was taking money out of their physician’s pocket. Others did not want to come in for visits because they knew the doctor would be reimbursed nothing for the visit.
I cannot even begin to address the questionable decisions that I observed by my fellow physicians at that time.
For those wishing to control cost, I applaud, but this idea will fold under the light of day
August 5th, 2009 at 12:42 pm
David,
The question is how do you ensure transparency to the degree that the patient understands the system and understands the incentive structure of the care they seek.
If the idea of network of doctors caring for patients is enacted—and the network is paid according to keeping their patients “healthy”, the public will need understand the breakdown of where the money goes and demand (along with doctors) that the dispersal is fair.
As far the $100 example, it’s egregious, no doubt. But my question is—without sounding to out-of-touch and altruistic—wouldn’t that $100 be worth it if the patient desperately needed to see that specialist? I realize that logic couldn’t be applied to every case, no doctor could sustain a practice. But in my time working for pain management specialist I was awed at the copious amount of unnecessary referrals. We specialized in treating mostly low back pain with injections. However we were often sent new patients who came into the office with the expressed sole interest of seeking physical therapy to manage their ailment. Basically they had to pay for an office visit they never needed, their primary could of just sent them to the intervention desired and saved the patient both time and money.
Increased communication needs to be at the center of all reform, and if all parties involved are willing to make compromises for the better of the system, I think we can figure this thing out.
Most of us cannot speak on your level of expertise about health care. Please don’t hesitate to share your ideas on how we can reform a system that is currently failing—thoughtful insight can never hurt a discussion.
-MCS