This expansion of coverage, however, cannot be a broadening of Medicaid and its dysfunctional payment system. It cannot be a single-payer, Canadian system, which creates irrational rationing and does nothing to address the need to bolster primary care. We need a new health paradigm where performance and access mean just as much as new technology.
More Primary Care
What good is insurance if you have no access? Just ask the citizens of Massachusetts, where the newly insured can’t find a primary care physician (PCP). One “benefit” of the economic downturn and stock market tumble is late-career PCPs can’t afford to retire. But primary care is in shambles, and throwing a few more dollars at PCPs or creating a “home” won’t make being a PCP more attractive to medical students. For a more revolutionary approach, check out the New England Journal of Medicine video roundtable (www.nejm.org/perspective/primary-care-video/?query=TOC) to hear of a “new” primary care model, which is more centered on population management than a series of 10-minute visits. Hospitalists, as much as anyone, need a strong, sustainable primary care partnership, if we are to tackle the difficult problems inside the hospital.
Value-Based Purchasing
This new payment model is being pushed by Sen. Max Baucas (D-Mont.), the powerful chairman of the Senate Finance Committee. Value-based purchasing (VBP) basically moves us away from just paying for care by the unit of the visit or the procedure, regardless of medical necessity or outcome. This plays into the strengths of hospital medicine where performance and communication are valued. Paying more when the customer gets more is an American value, which, at times, has been overlooked in American medicine. It is time we brought VBP into the healthcare equation.
Bundled Payment
All politics is local, and in many ways all healthcare is local. By changing the payment for hospital care to a composite fee for the facility and all the health professionals, an opportunity exists for the physicians and the hospital at a local level to creatively reward work, performance, outcomes, and patient satisfaction. This is not giving the hospital the entire fee, but more relying on a physician-hospital organization (as currently exists in many places in the country) deciding how to allocate resources. Once again, hospitalists are managing up to 80% of inpatients at some hospitals, so we are right in the middle of a new distribution of compensation for inpatient care.
Transitions of Care
It is time to look at our healthcare system from the patient’s point of view. It is not enough to perform the surgery perfectly or order the correct treatment. Patients need to be involved in their care, to clearly understand what medications they should be taking, to know who is responsible to answer their questions, and what their expectations for recovery should be. It also is an opportunity to prevent unnecessary visits back to the emergency room or readmissions to the hospital. The current, 15% readmission rate within 30 days for Medicare patients points to how broken the system is. Patients deserve accountability, transparency and clarity on their terms.
Once again, SHM and hospitalists have taken the lead in this issue. With a grant from the Hartford Foundation, SHM already has demonstrated practical strategies to improve the discharge process.
What It Means to You
In calmer, less-chaotic times, I suspect there would be calls for tinkering around the edges. But these are dangerous times that call for decisive, some might say, disruptive change. A new, patient-centered healthcare system based on access, inclusiveness, performance, communication, and safety is coming. There will be those who feel less well-off in the new order—insurance companies, some physicians and some hospitals—but there will be many who feel, for the first time, that the system is equitable, open, and responsive to their needs. The latter group includes U.S. business, some physicians (e.g. hospitalists), some hospitals, and, most importantly, the American people.