We have to stop paying for the unit of the visit or unit of the procedure, which just leads to more visits or more procedures—even if they produce no appreciable improvement in outcomes or quality of care. We have to start figuring out what outcomes we want and reward those healthcare professionals who can produce. If we want our diabetics in good control, pay for that. Don’t pay for just seeing the diabetic patient.
The cornerstone of value-based purchasing—which is our goal—is performance measurement. Hospitalists are at the head of the line in agreeing to be measured and in working with other health professionals and patients to set goals for ideal hospital care. We don’t mind being held accountable for our performance; we just want to be involved in ensuring we’re measured on what matters and that we have a plan for and a part in our improvement.
We also question if measuring performance at the individual doctor level makes sense. We believe healthcare is a team sport. We view our role as working with the entire healthcare team to deliver measurable, quality care. Our teams and hospitals need to be held accountable for performance and outcomes—and payment for care should be commensurate with performance.
We can talk about whether this takes the form of case rates or diagnosis-related groups for physician care: Both can reward efficiency and systems improvement. Or perhaps we should aim for pay for performance or pay for outcomes that would reward effectiveness and value. The recent decree by the Centers for Medicare and Medicaid Services not to pay hospitals for so-called “never” events (hospitalization errors that should never happen) is a good start. But we need to plow those savings back into rewards for high performance.
In the short term, if you can’t change the structure of the current payment system, at least stop these annual 5% to 10% reimbursement cuts. We are young physicians at the lower end of the pay scale, and there is little room for us to cut our expenses or stop paying our medical school loans. We are the front-line doctors essential to caring for the acutely ill, especially the elderly, and we need a payment system that makes it attractive for other young doctors to join us. Throwing out across-the-board payment cuts makes it more likely the new, younger physicians will continue to choose higher-paying specialties like anesthesiology and dermatology—just when we need many more hospitalists.
Reward What You Want
We are stuck in this payment system where we only pay for direct, face-to-face, one-on-one patient care. While this is still necessary, patients, employers, and the system cry out for a different approach.
The system needs to be reworked with improved throughput and efficiency. Seamless communication and coordination of care are primary goals. Reformed infrastructure and culture should foster development of highly effective teams of healthcare professionals. Time must be built into the work day for end-of-life care, palliative care, and joint decision-making by patients and their families.
All this takes dedication, expertise, professionalism, and—most of all—time. But in a payment system that rewards scoping an orifice or cutting out a skin lesion and still hasn’t figured out how to pay for changing the system or building a team, where do you think most physicians’ work time is driven?
Nowhere is it truer than in healthcare that you get what you pay for. There is plenty of money in the U.S. healthcare system—more than $2 trillion annually. The problem is we’re funding a system that may have worked in the 1950s, and we expect it to meet 21st-century needs.