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.

Fee-for-service is the wrong way to keep score

In today’s Globe and Mail, André Picard points out the foibles of Canada’s (mainly) fee-for-service (FFS) physician payment system.  Good points, but nothing new:

FFS is open-ended

FFS doesn’t value efficiency or cost-effectiveness

FFS creates an incentive for over-consumption/production

Alternatives to FFS carry their own baggage.  Capitation systems pay physicians a lump sum to provide all care for a group of patients.  That removes the incentive to over-treat, but there may still be gaming of the system.  Physicians may “skim the cream” by enrolling only healthy patients in their practice.  Same money, less work.  There’s also a temptation to offload patients with complicated/time-consuming conditions to specialists.

Pay-for-performance models compensate physicians when their patients achieve certain outcomes, often using surrogate measures like rates of screening mammographies or hemoglobin A1c.  There has to be reliable data collection in place, in addition to a way to disentangle the involvement of multiple care-givers.  Also, doctors may give attention to conditions whose outcomes are measured, while neglecting other problems.

Picard concludes:

There is no magic bullet waiting to be grasped, no single alternative payment scheme that will rein in health care costs.

 But there is a need to have the discussion, to experiment, to find a model that remunerates doctors fairly yet allows cost controls and improves delivery of health care to patients.

Very polite.  How about something a little more pointed…

In The Best Practice, Charles Kenney quotes George Halvorson, CEO of Kaiser Permanente, lamenting “a fundamental flaw in American health care: improperly aligned financial incentives.”:

“As a pure business model, health care is winning,” he says.  “Health care is taking all…your money and is doing it without having to be particularly accountable in how the money’s spent.  Based on that, health care will never, ever reform itself.  The model is too lucrative.”

 “There are no billing codes for cures.  There are no billing codes for outcomes.  There are no billing codes for care improvement.”

 “Providers,” he adds, “don’t do what they’re not paid to do.”

Of course, he’s talking about American medicine – things are different in Canada, right?

If we were to take André Picard up on his challenge to “experiment”, what would that experiment look like?  Maybe I’m mentally constrained by the fact that my income would be at stake in such an experiment, but I think the government/payor should be prepared to take the big risk first.  

If there is a trial of pay-for-performance, provincial medicare should totally abandon tracking volumes of service.  For most of the “alternate funding plans” (read: salaries, but don’t say it out loud because it spooks the docs) that I’m aware of, the physicians are obliged to “shadow bill”, that is, they continue to track their service volumes.  They have to do this because the health ministry thinks they will slack off if they are on salary.  And, truth be told, they might do just that. 

Which is exactly what we want!

FFS fosters over-service.  Over-service means inappropriate care and fruitless cost.  Taking away the incentive for over-service is exactly the reason for an alternate funding plan.  So, get rid of shadow billing.

But, how can we make sure the docs aren’t golfing all day?  Actually, golfing half the day would be fine, as long as the other half is spent providing appropriate, high-quality, timely, patient-centred care.  Measure it.  Report it.  

Celebrate the fact that doctors are working less, as long as they are producing the results we want.  And, for goodness sake, keep paying them the same.  It's a bargain.  Docs who are over-servicing generate tremendous downstream costs - CT scans, inappropriate surgery, unnecessary prescriptions.  Appropriate, high-quality care will be cheaper.

Perhaps we’re doing doctors a disservice by making money the sole outcome measure for their work.  If doctors seem to always have their eye on the dollar sign, maybe it’s because it’s the only target we’re giving them.  

Who has the nerve to rewrite the rules of this game?

Show me the money

The latest Saskatchewan Medical Association “President’s Letter” had some encouraging tidbits in it. The SMA and Government are negotiating physicians’ fee-for-service agreement. Usually the focus is on the percent increase in global funding to physicians, but this time the newsletter mentions some initiatives the Ministry of Health is proposing around Quality and Access. “Clinical Practice Redesign” and “Dedicated Quality Improvement Work” are noted as areas for targeted funding. They’re both laudable, if as-yet undefined, goals.

But, I’m most interested in the suggestion that funding may be given for “Physician contacts with patients via telephone and email”. I think this has great potential for improving patient access and satisfaction.

I’ve heard from many patients that they have trouble reaching their family physician (or specialist) over the phone. They may have a quick question that could be handled over the phone, but instead are required by “office policy” to make an appointment to see the doctor in person. Last month, my wife was quite annoyed at being subjected to this approach when she wanted to find out the results (normal, as it turned out) of my son’s xrays. She drove across town, and waited to be seen, all to receive 30 seconds worth of information. That’s not good value.

We shouldn’t be surprised that doctors require patients to come in for a “face-to face”. (See a previous post about this: “Awkward”) There’s no value (i.e. fee code) assigned to alternate ways of communicating with patients. I spend between 30 and 60 minutes daily returning phone calls and emails, as well as writing patients letters about results or follow-up. That’s an unpaid hour of work. I’m sure that lawyers and accountants would shake their heads at that.

Even though I plan to continue to communicate with my patients like this, whether I get paid for it or not, I can envision ways that I might change my practice if this alternate communication gets its own fee code. At present, I see phone calls as “extras” that I fit in between “real” (i.e. billable) visits. If I were to be paid for phone calls, I might schedule blocks of time to make them. I could get calls done during regular hours rather than after the end of the scheduled workday. Also, my staff could tell my patients when they should expect a call. That would be more convenient for patients, and would likely reduce the amount of phone tag frustration. I don’t like it when the cable guy says he’ll be around “sometime between 9 and 5 on Wednesday”, and I’m sure patients don’t like to hear a similar message about when the doctor will return their call.

Goats and Apples

OK, one last post about our recall rates/internal demand. I’ve been fixated on this topic for many recent posts, and it’s probably time to move on… after I show you this chart:

Looking good!

In July, 6 out of the 8 docs who were working had patient recall rates in the single digits, and the clinic average recall rate was 6.8%. That’s the first time we’ve had a clinic average in the single digits. We need to maintain these gains, and I think we’ll be helped by a change coming to our office this fall.

Awkward

The problem with first-year medical students is that they haven’t yet learned which questions not to ask.

Two weeks ago, I had a student spending the afternoon with me at my office. We met a patient and his wife, and talked with them about the results of a CT scan he had done earlier in the day. After the visit, the student asked me "Why did he have to come to your office today?" Her concern was that the man had difficulty walking and had recently moved into a care home an hour away from Saskatoon. It was a significant effort for them to travel, both to get to Saskatoon and then within the city.

My staff is diligent about scheduling CT scans (and other tests) on the same day as an office visit, so I can review the results with the patient. I pointed out to my student that this saves people an extra trip into town.

Then she got really impudent.