Pay-For-Performance

Ever heard of "Pay-For-Performance" healthcare?

It sounds like a great idea at first. The idea is that a doctor or hospital would get reimbursed for following a set of guidelines that could ensure statistically the best care for the given condition. Who is doing it? Mostly HMO plans. And here is the kicker, more than 50% of HMOs are doing it. To be honest, I am not sure if I like it or not. My frustration is that I feel the few will be ignored for the many. That some will suffer because they don't respond to treatments that others respond to. Most of you know I root for the underdog. I constantly treat the person who falls through the cracks of standard care. I treat those that are the few who don't respond the way everyone else thinks they should. As such I am mad that more and more people will fall into this category as they are shoved through a flow chart of protocols rather than the doctor being required to investigate. I am also glad because this means more people for me to treat. But this isn't really what I want.

A recent article noted:

"More than half of the nation's HMOs used pay-for-performance programs in their contracts with doctors and hospitals in 2005, according to a new study supported by HHS' Agency for Healthcare Research and Quality. More specifically, the study, which was published in the November 2 issue of the New England Journal of Medicine, found that nearly 90 percent of those included these arrangements as part of their physician compensation and more than one-third of HMOs with these programs included them in their hospital contracts. "
http://www.medicalnewstoday.com/medicalnews.php?newsid=55682&nfid=nl


What does this Mean for you?
This means that when your doctor sees you, they will get paid more if they follow a flow chart of what most people respond well to. This is good in that is helps motivate your doctor to give you the care most people respond best with, but on the flip side, it also means your doctor is getting trained consciously and subconsciously to think about your care in terms of the dollar. Now don't get me wrong, your doctor won't give you care just because of the dollar value associated, but what it does is create a pattern in your doctors behavior. It trains the doctor to always follow a certain pattern of diagnosis and treatment. When you're doctor gets in this groove, it is hard to get out of the groove. Doctors tend to create habits and follow them, they have to, they don't have a lot of time to spend with you. For the average patient, this is a blessing. But what if you aren't average. This can often result in a delay in the correct diagnosis or treatment. The problem isn't the idea, but the possible result.


As a society we are moving into a grey zone. I remember having the conversation as a youngster that went like this. "If you could save one thousand people, but had to kill one to do it, would you?" Twenty years ago most people would say "No way!". Nowadays most the people I ask say "It depends?" What? But more and more we know the true answer. We practice it and make it law. We say that destroying embryos for research to help bring cures to people is worth it. We say that sending troops to Iraq to prevent an attack on America is worth it. I am not bringing judgment on either of these statements. We all know that freedom isn't free. We all know that sacrifice is required in life. But where do we draw the line, is the line getting thicker or thinner.

What does this last comment have in regards to pay-for-performance?
This is the connection. When we look at people and health care through a statistic, we stop seeing them as individuals with unique needs. We de-humanize people and put them into categories. When this happens, the role of a doctor from being a teacher, investigator, and mediator will be changed to that of a technician. The doctor of today is slowly pushed into treating patients based on their insurance and statistical relevance. Doctors are scared, frustrated, and not sure what to do. They have seen this happen with the drug companies telling people what they want, and as a result M.D.s and D.O.s have become the mediator of therapies based on symptoms. Soon they will be more restricted into the mediator for the insurance company and the drug company.

Will more people get better d/t standards of care. Yes. Will everyone, no. What I predict is that we will just shift who isn't getting better.

Solution: Make your doctors work for you, not the insurance company. HOW? Get yourself a healthcare savings plan. This way you are covered for serious injuries and illnesses, but you pay for the care you get with your own pretaxed dollar. This puts health and healthcare back into your hands. Now your doctor is only responsible to you - not the insurance company. In addition to getting better care, you will save money, and build up savings in your healthcare account.

Live long if you're healthy! Live well, if you aren't! ~sv

Comments

[Dr. Samuels]

Hey doc, Can you post some more information on the healthcare savings plan. Is it a regular account or what?

Do you or anybody on this board know anything about care credit. How does it work? I heard that it's perfect for people with no insurance.

[Jack]

Yup, my dad is a doctor and he complains about the HMOs all the time. He always say that they make it hard for you to treat patients.

[Tracy]

Hello Dr,

What is your take on an MD/DC practice?

[Steven L. Vanden Hoek, D.C.]

RE: DR. Samuels - (please forgive the spelling errors)

HSA (healthcare savings accounts) are a combination catastrophic healthcare policy and tax free savings plan - very similar to an educational savings plan. These type plans are provided by your health insurance agent and go something like this. You get a BCBS policy with a $1,500 Deductible. You're premium is much lower because of this high deductible, you can then take the savings from the lower premium and put it into a savings account which you then use to pay for any care you recieve. Some programs even have checks or debit cards you can use which pull the money directly out of the account. The money you save earns interest, and unlike a cafeteria plan does, continues to collect interest year after year. In addition you don't loose the money at the turn of the year either.

In addition, you can spend this money on any healthcare, which means you dictate what is healthcare you want to recieve. Herbs, acupunture, massage, chiropractic, medical, drugs, etc.

If you do spend 1500 in a year, the insurance then starts up, usually at about 80%.

I have seen several reviews on these, and it is a government initiated program, so you should have easy access to info with a phone call to an insurance agent.

Good luck.

[Steven L. Vanden Hoek, D.C.]

RE: MD/DC?

The concept is great, the execution is usually poor.

I have had the pleasure of watching my father implement an DC/MD, DC/PT, DC/FNP, and DC only practice. They are hard to run ethically. This is because most MD/DC practices are set up for one main purpose - higher collections. For these docs they think getting paid is a game that you have to play. They use the MD to do initial exams and order therapy - the reality being that they aren't needed. While Chiro's don't normally see any error with this, let's look at this differntly.

This would be like a radiologist highering a family physician to work in his office so that he could have them order radiology studies for his business. Most people would shake their head at this idea, just as the Feds shake their heads at us. Really, we don't need an MD to preform an exam for us, we don't need them to treat our patients, and we don't need them to refer to others. This usually means we need them for money.

Now, having an MD work in your office to provide medical care is ethical, and a smart business decision. Having an MD work in your office for to justify chiropractic and make more money on these servcies is not.

Call me skeptical, but most docs I konw didn't bring in the MD for the patient, but for the pocket book. And yes, money is important, but when your motive is money, everyone wants a piece of it, and you become suspect to those you don't want to mess with.

So in summary - I don't like MD/DC clinics unless it is so two distinct services can be offered. I do like clinics that have MD's and DC's working in the same environment, along side each other, but not for each other. I hope that was as clear as mud.

Best of wishes.

p.s. Same goes for DC/PT - but usually not as bad as DC/MD.