Monday, January 12, 2009

The New England Journal, Physician Compensation and the Medical Home

Gasp! Physicians are being pressured to make money! Health care is a business! Woe.

This is the doom and gloom insight of Drs. Hartzband and Groopman in a perspective published the latest January 8 New England Journal of Medicine.

The outcome of this bleak state of affairs you ask? Well, according to these authors, doctors may not freely share their medical opinions with colleagues, expecting instead to be paid. Communality will evaporate in a pernicious web of market-driven bartering. Lacking a sufficient reward, providers will regress to the lowest ratio of effort to reward and, if it's not worth while, go home and watch Oprah or, better yet, learn ophthalmology. No wonder primary care physicians are opening concierge practices. And thank goodness the 'patient centered medical home' (PCMH) has been invented. It emphasizes a 'social exchange that exists in a family,' is a "compassionate partnership," and is expected to yield up 'substantial cost savings.' Be warned policymakers: there's a difference between reimbursement and money. The former fosters physician collegiality, cooperation and teamwork. The latter promotes meanness, evil doing and being naughty.

After reading that article and reaching for the Compazine, the Disease Management Care Blog awards these two Boston academics the Arnold Relman Physicians Should Be Salaried Award. While they’re basking in that recognition, they should also know that the economics of their practice environment make for great preaching but have little basis in the other realities of mainstream clinical practice. What’s more fee-for-service isn’t all that bad. Paying physicians per ‘service’ is not all that dissimilar from paying physicians for performance which, despite some DMCB doubts, would probably be welcome even in Boston.

The DMCB heard an anecdote and it believes it. It was told by a salaried physician at a very large group practice that the most dangerous place in the city was that group’s doctors’ parking lot at 5 PM. As patient access and physician productivity declined, the administration stepped in with ‘variable pay’ with incentives. Once the docs felt the link between their salary and how hard they worked, the spectacle of physicians rushing out of their clinics at the end of a 9-5 workday ceased.

Let’s face it. Physician compensation will be a mix of fee-for-service and capitation for the foreseeable future. The former increases utilization while the latter blunts it. The DMCB predicts this ‘gas pedal and brake’ approach will probably be fine tuned to promote and/or blunt underused and overused services, respectively. The good news is that both systems of payment have the potential to reward docs fairly and richly – assuming it’s done right.

Last but not least, the DMCB wonders what the PCMH has to do with fixing physician compensation. The notion of a medical home has merit but is it really going to turn primary care into the paradise described in this article?

Really?

3 comments:

Brady Augustine said...

The Federal Government and numerous stakeholders have probably spent tens of millions of dollars writing reports that provide no better understanding than your words in this post. FFS encourages overutilization and capitation encourages underutilization...thus a combination of the two will help find the sweet spot.

This is one of the allures of the medical home model. If we pay appropriately as described for management and coordination (not $3 PMPM as is done in Medicaid) and reduce unnecessary burden, it might not be such a hassle to navigate the health system. We can only hope that clearer minds prevail. ~Brady Augustine

www.medicaidfrontpage.com

The "medical home" is not the silver bullet but it a valuable tool in the toolbox, so to speak.

Jaan Sidorov said...

I'm glad you brought this up because in my next post, I look at the prevailing monthly fee (ie capitation) for the medical home. Not only is it ironic that physicians are now embracing capitation for the medical home, but I predict they'll eventually ask to have it converted over to fee for service.....

Brady Augustine said...

As they say, everything old is new again and the medical home is a perfect example...everyone talks as if it is something new but it has been around for 30+ years.

The sine wave representation in your next post is great. That is what I found at Medicare, a public interest in bundling and then concerted efforts by providers and manufacturers to chip away at the bundle. ~BAA

www.medicaidfrontpage.com