Healthcare Reform-Pay For Performance

All the talk of rising healthcare costs and unemployment swelling the ranks of the uninsured has pushed healthcare reform to the top of the to do list. Those of you who are concerned about “socialized” medicine should really try to get that picture out of your minds. You know, the one where hundreds of people in ratty clothes are lined up outside a community health clinic in a poor run down area waiting to be seen by the only doctor in town. Instead, picture this. Your 60 years old and suffering from diabetes. You have a doctor who has the time to listen to your concerns and properly examine you twice a year to be sure your diabetes is under control and that your disease hasn’t effected your heart, kidneys, feet, or eye sight. His nurse calls you a few times a week to be sure you checked your blood sugar, taken your blood pressure, and refilled your medications. This is a much better picture, don’t you think? It is attainable with careful planning.

Currently, the U.S. has one of the worst healthcare systems in the industrialized world. BELIEVE IT, IT’S TRUE! By all measurable parameters we score pretty low. For example, our over mortality rate and infant mortality rate is among the worst. Additionally, we only receive about 50% of the healthcare we need to manage disease. Only about 8% of diabetics get the care that I described above for diabetes! Shocking, but true.  Another example is only 60% of women get an annual mammogram to detect breast cancer and in those women who have breast cancer, only 50% receive the appropriate treatments. The data is even worse when you measure the variation of care across states.

It is interesting that much of the “routine” care that we need which is not very expensive is unattainable, yet, we receive the excessive unnecessary expensive care to the tune of $700 billion a year. You probably heard on the CBS evening news last week about the unnecessary coronary bypass surgeries that are performed each year. Scientific, evidence-based medicine has shown that bypass surgery should be reserved to only the sickest of patients with heart failure-those with three vessel occlusion or occlusion of the left coronary artery. Yet, bypass is done on patients with one or two vessel disease  when insertion of a stent would work just as well. Why is this? Well, providers are paid based on the number of procedures they perform-the more bypasses, the more dough. The more MRI’s the more dough (X-rays are cheap) (http://www.nytimes.com/2008/12/09/health/09scan.html?_r=1&scp=2&sq=meniscus%20surgery&st=cse). On the other side of the coin, the more time you spend involving patients in their care, the less money you make-docs are not paid for talking or for performing exams that keep you healthy, so they must see lots of patients.

Many of my friends would rather see more done to treat them rather than less.  Because more must be better. However, you must realize that more is not better, indeed, it has been shown to be worse. It’s dangerous to be in the hospital and it’s foolish to be hospitalized when it is not necessary. For example, there are hundreds of thousands of preventable injuries that occur in hospitals every year which results in about 100,000 reported deaths! Why would you put yourself at unnecessary risk if the science says that the procedure you’re about to undergo is unnecessary?

So, we’re in a dilemma. We cannot get the inexpensive care we need to prevent (or intervene) chronic disease, but, if we have the means, we can get excessive unnecessary care to our  heart’s (no pun intended) delight. How do we fix it? Now is the time you must become involved in this debate. President Obama says he cannot do this alone and he is asking the public to make a difference. You can make a difference by telling your representatives in Congress that before we jump into universal healthcare we must come up with a plan to reduce healthcare costs (http://www.washingtonpost.com/wp-dyn/content/article/2009/02/23/AR2009022300288_Comments.html). There have been many studies that have shown that if we alter our reimbursement policies from fee-for-service to fee based on performance (keeping the patient well and out of the hospital), healthcare costs would go down precipitously. Doctors who provide the kind of care described for diabetes, above, would receive better pay. Doctors who perform bypass surgery that results in a patient suffering a stroke would get paid far less. 

Additionally, docs should get more money if they provide counseling and other help to prevent disease. Smoking cessation counseling following a heart attack should be rewarded, and obesity screening and counseling should be rewarded because they save money.

One thing we can be certain of is increasing access to healthcare with universal coverage without changing our behaviors and reimbursement policies we will not reduce costs.

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