A lot of healthcare system pundits including the current leadership of the American Academy of Family Physicians feels that fee-for-service payment is the root of all healthcare waste. Obviously, I disagree.
Their line of thinking is based on the existing evidence that there are too many joint replacements, cardiac stents, cardiac tests, etc., because the orthopods, surgeons, and cardiologists are paid for volume not value. They say fee for service is the problem. I say the way the services are valued are the problem. If we want surgeons to operate on fewer marginal cases, pay them more to think and less to cut. Make the incentives match the behaviors you want. If you really don’t want them to cut, maybe pay them something extra for every patient they decline to operate on.
Their line of thinking is also based on the early evidence of some of the direct primary care approaches, such as Qliance in the Seattle area. They have some good numbers on the total cost of care that shows it can be reduced when family physicians are given time to think and be thorough. They achieve this by providing 30 to 60 minute appointments with their patients, plus phone access, email access, and extended hours on evenings and weekends. Contrast this approach with the feds (Medicare/Medicaid), which doesn’t allow family physicians to be paid for phone visits, email visits, or taking care of multiple problems at one visit. If you ever wondered why your doctor tells you to come see him for something you thought could be handled over the phone, it’s because the feds and private insurance companies only pay us for face-to-face visits.
I say another way is possible. If a patient asks for help for a quick simple problem (UTI, controlled blood pressure, e.g.), I think the existing payment system pays us too much. But that isn’t the problem. The problem is that patients come to us with an AVERAGE of 3-4 issues they want addressed, but we’re only paid to deal with 2 of them. I say if a patient wants help with 8 issues, then I should be able to schedule a 30-60 minute appointment, but be paid more for dealing with 8 issues.
It’s like you went to a Target. If you buy one thing, your bill lists one thing and the price is low. If you buy a shopping cart full of things, the bill is bigger and lots of items are listed on the bill. I just think this approach incentivizes the right behaviors on both the doctor and patient, and the bill generated makes sense to the patient (“Yeah, we talked about my blood pressure, cholesterol, migraines, eczema, and foot pain”).
I have created a payment system based on these principles that I polished during my year as a CMS Innovation Advisor. If anyone is interested, I’m happy to share my plan.
But let’s not call this fee for service, because a lot of people will blow it off based on that label. Let’s call it fee for thinking, or fee for comprehending, or fee for thoroughness, or fee for listening well, or even how about fee for really caring?
The Qliance innovators created a mechanism to pay family physicians to have more time talking and listening to their patients. I say that other mechanisms that achieve a similar endpoint should be tried as well.