Payment reform initiatives
that rely on financial incentives tied to individual quality and performance ratings
of doctors and hospitals carry a serious risk of unintended adverse
consequences. Much of health care is too complex to be amenable to valid
quality ratings anyhow. Rating individual providers will quickly induce them to
game the ratings by up-coding diagnoses or avoiding sicker, atypical, and more
complex patients, or it will drive them to refuse plans that impose such
ratings. Attempts to correct for these problems require complex information
from computerized health records and are fraught with problems. Many older,
less tech-savvy physicians are likely to retire rather than accept enforced
computerization, and with our nation-wide physician shortage we cannot afford
to drive a large number of physicians out of practice.
Instead of rating individual
doctors for pay-for-performance, quality improvement efforts should be based on
the Continuous Quality Improvement (CQI) model, as exemplified by Intermountain
Healthcare in Utah.12 This model defines problems as systems
problems, not problems with individual doctors, and engages all doctors
cooperatively in improving care. It means focusing on processes of care and
transitions between care settings. It encourages reduced variation in practice
patterns without punishing doctors for deviating from guidelines when there are
good clinical reasons to do so. It means health IT is not focused on measuring
for selection, but on measuring for relative improvement. It does not require
all doctors to have an EHR, and it requires less disruption in physician
workflow. CQI harnesses physician professionalism to improve care and make it
more cost effective, rather than relying primarily on financial incentives.
Achieving cost-effective, sustainable health care
We must abandon the idea that competition among health
plans can make care more cost-effective. Competition adds administrative complexity and cost for both plans and
providers, and interferes with efficient delivery of health care. It does not
reduce total health care costs, but does push plans to try to exclude the sick
from coverage, reduce benefits, and increase administrative burdens, all of
which are destructive to health care. Fragmentation in health care financing
also impairs quality improvement efforts, which work best in a universal system.
We need consolidation of health plans
under an administrative structure that is accountable to effective delivery of
health care.
Universal access to care is crucial to
ensuring that health care is delivered in the most cost effective setting, minimizing
use of emergency rooms and hospitals. Significant savings from administrative
simplification depend on universal access, and quality improvement is much more
effective when everyone in a community is included.
Solving our physician workforce problems will require improved pay for care coordination and cognitive
services, and correcting the imbalance in pay between procedural specialties
and primary care. With a universal system, CPT procedure codes could be
replaced with a simplified time-based system, with multipliers for training and
overhead costs needed to practice a given specialty. An expanded program like
the National Health Service, with government subsidies for medical education in
exchange for a commitment to practice in under-served specialties and
under-served areas, could remove medical education debt as a deterrent to
entering less lucrative specialties such as primary care, psychiatry, and
general surgery.
We need to promote professionalism among doctors. I am in favor of requiring all physicians to be
members of a professional organization, tied to licensure, to ensure their
participation in system-wide quality improvement, peer review, and continuing
education. Physician professionalism, not pay-for-performance, should be the
primary driver of quality improvement and cost containment efforts. It is more
effective and costs less than managed care administered by an insurance plan.8,9,12
Cost-effective, sustainable
health care will require a much simpler administrative structure, universal
access to necessary care, and organization of doctors to promote quality
improvement. Accountability must always be to the health care needs of the population
served.
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