Payment reform key to fixing health crisis
Physicians usually perform in the interests of their patients. But they do so in an environment that fails to offer incentives for basic preventive services and good chronic disease management. This fact compromises the patient’s future health and assures that the costs of care will escalate.
Perverse payment programs promote the progression of chronic illness by abandoning the cause of prevention. They stifle innovation as well. Electronic medical records, medical homes, even quality patient education: all require investment, time, and a long-term view. That’s precisely the kind of thinking fee-for-service medicine omits. One could make the same argument for reducing waste and inefficiency; these efforts, too, often run counter to profit.
So what does payment reform look like? It recognizes and rewards health improvement activities and leads to outcomes that matter to patients (am I getting better?) and society (is care cost-effective?) Cooperatives like our own Group Health and HealthPartners in Minnesota have had success in doing this. Financing and delivery of care are entwined in the same enterprise, while largely salaried physicians hold no monetary stake that would influence the choice of one treatment over another.
Talk of clinical restraint and evidence-based formularies invariably spur concerns about gate keeping or rationing. No one wants care withheld from them. Respectful and honest conversations—an extravagance in fee-for-service medicine—make it more likely doctor and patient will together determine an intervention that is neither too much nor too little, and that minimizes risk and maximizes gain.
Once we remove financial self-interest from an intrinsically selfless enterprise, the true work of reform can begin.