How to pay the Doctor?

Since the most remote times people have asked themselves this very stressing question: how can we pay the Doctor (or the Shaman if the times were even more ancient).

Hospital (Photo credit: José Goulão)

Hospital (Photo credit: José Goulão)

Most part of the time, in the countryside, where money was rare, the practitioner or care provider or whatever name you give him, was paid with a chicken or a basket of vegetable.

But when the prices went higher and higher, especially when Doctors needed the environment of a hospital facility to be more efficient, to give the all farm or the entire herd of cow would not have been enough. So hospitals then after them Doctors themselves decided to give incentives to the population to be more foreseeing by creating mutual funds aiming to finance their potential needs of care.

But for those funds the question still remained the same: how to pay the Doctor (or the hospital, or the nurse etc…).

The first step was to pay for the time spent, the number of Doctor’s visits needed or the devices that were used. But the more the patient stayed at hospital or the more the Doctors used devices or made visits the more they were paid. Then the funds decided not to pay for the service in itself (fee for service) but instead for the seriousness of the pathology which needed to be cured (diagnosis related groups). But here also the insurance funds saw a potential problem: what if the Doctors or the hospital, once paid for the so called pathology did not enough to cure it (eg not enough visit, cuts in the devices really needed, shortening too much the length of stay at the hospital and so on)? Consequently to this suspicion of drift came one more step to the answer to the question “how to pay the Doctors (or the hospital)”: the funds will pay only if the Doctors are well-organized (Health maintenance organization or HMO with gate-keeper, disease manager and plenty of complicated procedures to be followed by the specialists as well as the primary care practitioner). But the HMO didn’t keep their promises and the cost of paying the Doctor kept on its escalade at an even faster pace. Then after came the ultimate step of the chain of solutions imagined to pay the Doctor without starving once the debt is paid: the financial reward of the Doctor should be proportional to the quality of the care (pay for performance): the question is not only what has been done, not only for which disease, but also was it efficient?
In the meantime the accountable care organisations (ACO) of the Affordable Care Act was voted under the Obama administration which intend to bundle the finance of the health care without making a difference between ambulatory daily cares and in patients treatment. But in my view I doubt that the ACO will perform better than the HMO did given their similarity.

More content:
Healthcare reimbursement will change dramatically in the future
by DONALD TEX BRYANT

http://www.kevinmd.com/blog/2012/04/healthcare-reimbursement-change-dramatically-future.html

Looking for Solutions in a Rapidly Changing Health Care Environment

http://knowledge.wharton.upenn.edu/article.cfm?articleid=2963

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Provider incentives

Provider financial incentives, does it works?  Reuters report some concern on the issue expressed by a Professor of health economy, Jim Burgess, Director of Health Services Research at Boston University.

The US, the UK, Canada, Germany and recently France implement different incentive schemes to reward primary care physicians who perform quality in cares.

But the intervention may lead to adverse effects as observed in those two systematic reviews of the literature, one in 2009 and the other this month of 2011.

Professor Jim Burgess advises to target the whole-patient health instead of limited areas of health as counterpart of rewards for doctors.

We made earlier a post on the subject of pay for performance in France.

P4P for French primary care physicians for the first time of their history

For the first time of their history, French primary care practitioners will be paid for performance. Until now their remuneration was only of “fee for service” type. But the new contract with social security scheme of July 2011 introduces a dose of “pay for performance”. Goals that will have to be reached in order to receive bonuses will be fixed by the contract negotiated with the French national social security scheme.

Old time when practitioners only had an obligation of mean is from now on a past history. Bonuses are now also paid for the obtaining of results.

The risk of such a new remuneration is that it only add on to the previous one “fee for service” remuneration without address the problem of repetitive un-necessary medical cares.

Pay for performance should potentially show better results in a salaried context like in England than in a fee for service context like it is in France.

Furthermore patients with multiple chronic diseases often do not correspond to any guidelines available.  But… wait and see.

All the more, results depend on how generous will be the financial incentive and how high will be set the performance thresholds. From now on bonuses costs are estimated between 360 and 380 million Euros.