Tuesday, July 19, 2011

Physician funding: Let's try an evolutionary model


Dilbert's Guide to Health Economics!

Yesterday's Dilbert cartoon reminded me of a health care story from Prince Edward Island. In May, PEI's Health Minister took salaried doctors to task for lack of productivity.  Apparently, fee-for-service doctors were seeing many more patients than salaried docs.  The same phenomenon was noted even if it were the same doctor, working after-hours in a fee-for-service clinic, after finishing a day's work in a salaried position.

Paul MacNeill's op-ed illuminates the economic and political issues around the Minister's actions.

Whether or not the accused docs are actually slackers is beside the point.  The reduced throughput for salaried physicians is exactly the result that the Minister should expect from these different payment schemes (neither of which is perfect).  Fee-for-service (FFS) encourages the provision of more services or visits.  Salaried positions are supposed to encourage physicians to provide more preventative care and counselling, spend more time with each patient, and engage in multidisciplinary care.  This means fewer patients will be seen, yet their quality of care should be higher.  Unfortunately, salaried positions are open to abuse, and some physicians (like other human beings!) may be tempted to do as little work as possible.

To judge physician performance, the Minister should look beyond patient volumes.  More appropriate measures would be patient satisfaction, health outcomes and wait times.  Of course, these are more difficult to measure and interpret.

What is the best payment system for docs?  (Oops - that should read "best payment system for patient care"!) Here are some thoughts from an expert.

And here are some thoughts from an amateur:

We can't create a foolproof physician reimbursement system in one shot.  It's too complex.  It should be an experiment where both sides (payer and physician) trust each other and that they have a common goal of excellent patient experience and outcomes.  The system would evolve to suit the needs of patients, physicians and the payer.  Start with our best guess of a suitable payment model, agree on goals, and get going.  Be flexible and make adjustments on the fly.

Don't try to create a definitive system.  Rather, create the conditions that will allow for a suitable system to develop:

  • Physicians are assured of a stable income and work-life balance. 
  • Payer is assured that at least the current level of service will be maintained. (This might mean making baseline measures of the current state using the new measurement system.  See below.) 
  • Agree on appropriate measures that suit the desired outcomes.  As noted above, patient satisfaction, health outcomes and wait times could be measured. 
  • Don't penalize docs when they run up against barriers in parts of the system beyond their control. 
  • Stop measuring volume of service.  Completely stop.  Don't make docs "shadow bill" to make sure that they are keeping up a certain volume of patient visits.  This wastes administrative effort that could be directed to quality improvement and patient service. 
  • Time spent on improving care delivery is as important as care delivery itself.  Quality improvement work is included as part of the physicians' duties.  (Likewise, education, research and administration.)
  • Fail forward.  Encourage reasoned experimentation.  Import best practices from around the world.  Expect failures.  Embrace failures.
I'm sure Dilbert would approve.

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