Pyrrhic Victory

During recent lobbying for his health care reform platform, US President Obama praised organizations such as Intermountain Health for being role models in providing high-quality care, without skyrocketing costs. Obama echoed comments made by a senior Intermountain executive: “Much of the rest of the country tends to focus on the volumes of health care services they provide, because that's what the system rewards, rather than the care that's necessary to help the patient.”

Bingo.

Have you had the chance to read “On the folly of rewarding A, while hoping for B” yet? According to this classic essay, we should expect exactly the system we have, that is, pay me fee-for-service and I’ll give you lots of service. And don’t call me greedy; we’re all responsible (via elected politicians) for supporting this dysfunctional system of rewards.

In a fee-for-service system, it’s challenging to deliver incentives for doctors to pursue quality improvement. I’m fortunate to have very generous partners who give me several half-days every month to work on various projects. They pay a financial cost – because QI work isn’t compensated in Saskatchewan – and have an increased workload.

Will they eventually reap rewards from our ongoing efforts to redesign our practice? There’ll be the professional satisfaction of providing better access and all-around care for our patients. We hope that achieving our Advanced Access goals will make our schedules more flexible. There’s plenty of potential, but the fee-for-service payment system means that if we succeed, we also lose.

June’s stats show that our docs continue to reduce internal demand by returning patient care to primary care physicians. Over the last year, our overall average recall rate has dropped from about 17% to 11%. We don’t know what the optimum recall rate is, but I suspect there’s still room to improve further. But if we’re successful in dropping the recall rate, and maintaining that change, then there’s a price we’ll pay. Literally.

The number of family physician referrals (external demand) we receive remains steady. As we reduce our recall rate (internal demand), we may eventually reach a point where our capacity exceeds demand. Wait times should be very short at that point, but we will be providing fewer services/consultations. And that means... less pay. Oops.

The status quo brings a certain income to fee-for-service physicians. Efforts to redesign clinical practice eliminate over-service, and so may reduce income. What would you do if you found out that doing a better job meant getting paid less?

Something needs to be redesigned. And it’s not just our practice.