Paying Doctors for Quality, Not Quantity

Medicare Experiments with Pay for Performance Programs

(CBS)  It's the president's favorite line about what he would change in health care: "The warped incentives."

Warped incentives meaning that doctors get paid for each service they perform, whether it helps the patient or not.

But on this key reform, paying doctors for quality, not quantity, Medicare is ahead of the president, reports CBS News correspondent Wyatt Andrews.

For the last four years, doctors at Dartmouth-Hitchcock Health in New Hampshire have been part of a Medicare experiment that pays for quality. Doctors get paid for seeing patients, and get a bonus for patients that get better. The clinic gets extra money for high scores in 36 areas, like controlling the blood sugar of diabetics or keeping heart patients on cholesterol drugs.

To keep track, nurses regularly call every patient - as often as it takes - to keep them healthy and out of the hospital.

Special attention goes to patients who've been in hospital - to keep them from having to go back.

Nurses call patients as often as it takes. Patients like Dick Harrington, who is on Medicare, get calls to remind them to check their blood sugar.

All that contact earned Dartmouth a $6.7 million bonus payment - 80 percent of the $8.4 million that Medicare actually saved by avoiding expensive procedures.

Around the country, 10 physician groups are conducting these pay for performance experiments, but the truth is they don't all save money every year. All 10 of the groups improved the health of their patients, but found that saving money on the elderly can take years.

"This is part of the answer," said Barbara Walters, the senior medical director of Dartmouth-Hitchcock.

So when the president calls for payment reform, almost every health care expert says he's right. But the amount he can save, no one knows that for certain.

[sollenbc]

Everyone who thinks that this is a good idea just isn't familiar enough with the medical industry. Specialists get paid more money than primary care doctors because they have more specialized training. They also have higher malpractice insurance premiums because they take on higher risk. And, for lack of better words, they work harder...they take call, they admit and take care of patients in the hospital in addition to seeing patients in their office (a practice that has fallen out of favor with most salaried primary care physicians). The mortality and readmission rates of a specialist are higher than those of a family practice doc. In addition, how do you assess these figures for family practice docs when they rarely admit patients and are rarely considered the treating physician when a patient is critically ill? In addition, some specialists only see patients that have difficult disease states. For example, a neurologist will treat epilepsy, parkinsons, stroke, MS, and a whole slew of disease state that don't "get better" quickly. Do we pay then the neurologist less because he is dealing with some of the toughest disease states? People, these medical issues are not like treating high blood pressure which has numeric goals where "quality" is determined by a quantitative absolute number.

It also does not take into effect that unfortunately Americans are very resistant to change. How many of us know people take blood pressure and cholesterol medicine that still eat bacon, smoke, and drink? They feel it is the medicines job to do the healing. If a person loses 10 pounds they significantly reduce their blood pressure, cholesterol, and life expectancy. If the government is going to hold docs accountable for their quality of care, why would the government then not have the power to exclude patients from getting healthcare when they are not willing to lose weight and help themselves. If the government is the payer of benefits, and the patient chart shows that they are not getting fit, why should the government pay for their medicine or treatments.

In addition, in rural america, we don't have many specialists to begin with. These docs see everyone...they are compassionate and work their tails off to see, yes, even those who can't pay. Find me a country doc that hasn't cut a patient a break. Docs that belong to a private practice (not hospital employed) often don't even have the resources to go after people who don't pay. These private practice physicians who still see medicaid and medicare will be crushed by these provisions and paycuts. That is why you see so many specialists who won't see medicaid / medicare patients. It is a doctors choice to treat who he wants. I don't support that, it is just fact. So the docs who have been compassionate, taking medicaid and medicare, who have had to carefully balance their overhead will now see a 20% in their revenue. And for those not familiar with business, a 20% cut in revenue is not a 20% cut in pay....since overhead stays the same. It can be up to a 50% cut in pay.

The impact of this, that no one seems to discuss, is how putting private practice docs out of business impacts the cost of healthcare. Private practice docs must compete with hospital employed docs in the area. The hosital employed docs get a salary and typically refer all of their lab and services (like xray and mri) to hospital. This helps ensure the success of their employer who signs their paycheck. It also puts out of business private labs, mri businesses, that actually charge less for services. If the government and hospitals put more private practice docs out of business...this will in turn decrease revenue for the private companies that compete with the hospital. The hospital has more power to set prices, which increases health care costs. THESE ARE FACTS NOT PROPAGANDA. Just call your hospital and ask them about prices on services. You will see that they charge more than their privately owned counterparts.

What bothers me is I do not hear politicians, the president or journalists discussing these real life details. It is ashame that Americans are not armed with the truth. Then we could all make educated decisions as opposed to picking our team and letting our team leaders dictate what is or is not important.

[aChangeOfIdeas]

Quality or quantity, a choice we all must make.
It sounds good, but here's the downside, it's already hard to get a new doctor when you move, or when one retires. You call around everywhere and they aren't taking new patients. With all the time spent on each patient using this system, the docs will whittle down the number of patients they see, making it even harder to get in. Or, won't accept you as a patient because you don't appear to be a good 'candidate' for getting better. A salary or hourly rates won't make much difference either, then you could really cut down on your patient load.

[mars7578]

This is a bad idea.The government or private industry should either set salary or hourly rates.Many industries are trying to evaluated every task to determine performance.In most cases ,they get doctored results and bad service such as the present hmo models.Before all this evaluation,professionalism produces a very high level of excellence.I can not name one business where service is as good since all this evaluation.Let medical professionals forget about compensation and concentrate on medical decisions.

[sjc_1]

HMOs put pressure on group doctors to run the patients through, it is quantity not quality. However, the doctor has to pay malpractice insurance premiums that continue to rise. They are caught in the middle between the HMO that tells them to hurry and treat lots of patients and the insurance people looking for a reason to raise premium payments.

[cowpow61]

Your report does not address the increased cost to the medical office to hire additional nurses to phone patients. Who pays for that increased cost if the medicare bonus fails to cover it? Is it truly a bonus if all the additional funds are assigned to the increased overhead to manage phonng noncompliant patients? Will the other insured patients and those rich enough to pay for all their care have their costs raised to make he medicare patients more compliant? Will the medical equipment and procedures available be at a lower quality to compensate for the additional staffing costs?
What's next... dentists calling everytime we eat and don't brush?
What impact is all of this control on reimbursement doing to the entering GPA's in medical school?

[iam4honesty]

What a novel idea. Pay for performance. Attorneys and others need to be put on the same program.

[rednomo]

GINGRICH: And the fact is, overall, 71 percent of Americans are relatively satisfied with the health insurance.

JOHNSON: But we have 46 million uninsured.

GINGRICH: Right. And we have ? you know, that means you also have 260 million insured.

BRILLIANT!

[rednomo]

Perhaps because he hasn?t had to shop around for health insurance for quite a while, Gingrich doesn?t know that it?s not that easy to just ?change insurance companies? if you?re unhappy with your current provider. Aside from the fact that insurer consolidation has resulted in limited choice and higher profits for insurers, those seeking insurance on the individual market face higher costs, as the Commonwealth Fund has noted:

Insurance in the individual market is often impossible to obtain or unaffordable. Nearly nine of 10 people who explored obtaining coverage through the individual market never bought a plan, citing difficulties finding affordable coverage or being turned down.

If private insurance companies have ?done well? and a public plan is no option, how does Gingrich plan to reform health care?

[rednomo]

75 percent of Americans who have been "pushed into personal bankruptcy by medical problems actually had insurance when they got sick or were injured." Many experts say that fixing the health care system will not mean "simply giving everyone an insurance card." Too many Americans "already have coverage so meager that a medical crisis means financial calamity."

[CitizenMikeM]

IThoughtItWasFunny2...

One person's "destroying this country" is another person's rebirth of this country.