Better Care; Better Money - Basing Physician Payment on Outcomes


Paying physicians based on outcomes rather than based on the number of procedures or services performed will ultimately reduce costs, entice more residents to select primary care, and lead to better care for patients.

Last week we discussed "perverse incentives" -- as seen in the example of a physician telling a patient to stay in bed for three weeks when that physician could not get a surgical fee. I asked: "What do you expect? It's human nature."

What is the cure for these shenanigans? Simple: pay for outcomes, not only care processes. If I, as a pediatrician, keep up with continuing medical education, keep an effective 'medical home' for my patients, make myself very available, and practice state-of-the-art and compassionate healthcare, then I should be paid more. Reimbursing doctors in this manner should help us get more primary care physicians into the mix. This is a BIG problem that urgently requires innovative thinking if we are to find a solution.

In fact, we should pay for prevention specifically and pay primary care practitioners better in general. And while we're at it, we should pay less to specialists who are churning business, delivering cost-inefficient and low cost-benefit, and those who are overcharging.

In healthcare, sometimes "Less Is More." That is, often times "some measures of health are worse in areas where people receive more health services." This may seem paradoxical, but it has been shown to be true in many instances, including the use of antidepressants in "persons with less severe depression," the use of screening mammography in absolute (not relative) terms of risk versus benefit in younger women, and in the case of the "serious adverse effects of proton pump inhibitors" in the treatment of peptic ulcer disease and GERD.

"There are many reasons why clinicians in the United States may provide more care than is needed," but why are we allowing incentive misalignment? Why don't we track and do something about over- or under-treatment? As I said at the outset, it's time to get away from the insurance model; they are not doing their job right by you or me. I'm tired of paying the fox to watch the chicken coop!

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