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Family Physician Payment – A Lesson from Switzerland

June 27, 2016

There was a nice opinion piece in JAMA Internal Medicine recently where the primary author talked about moving from the U.S. to Switzerland and his experience in both systems. Primary care physicians are allowed to bill based on time there. This includes travel time, phone work, and documentation time. What a concept!

The authors state and give references that Swiss patients are the most likely to feel listened to, have their goals discussed, discuss treatment choices, and received clear instructions. Swiss physicians are the least likely to prescribe antibiotics and are low on the use of imaging. As the authors correctly state, “Reassuring a patient instead of ¬†providing unnecessary testing or imaging takes time.”

Australia allows its general practitioners to bill for travel time, so Switzerland is not alone in that feature. It’s experience stands in sharp contrast to the direction both CMS and the AAFP are trying to push primary care into essentially the old manage care capitation model: $X per patient per month.

I have always thought that what I have learned to call fee-for-thinking is the best way to recognize and reward family physicians. (When one says fee-for-service, the pundits’ brains freeze and they can’t hear anything else that is said. They’re convinced fee-for-service is the problem).

One can only hope that the leaders of CMS and the AAFP have not completely closed their mind that maybe other payment options should be experimented with, not just the PC idea of the moment. The AAFP has a storied history of screwing up major moments in healthcare evolution: promoting gatekeepers under managed care, believing that EHRs would save family medicine, and now capitated payment for simplistic quality metrics and population management. May the cowbells of the Swiss experience ring loudly in their ears.



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