Continued from Part 1
Let’s go back to our little button from Part 1. Imagine that our button is one of many buttons, because the button/dial administration is giving them out to anyone who asks for one, no matter if they have any chance of hearing a bell or not. Well, it’s now becoming common knowledge that no-one is really paying any attention to the button pushing. It’s also becoming common knowledge that dial-turning is really getting watched closely. In fact, the button/dial administration is really cracking down on dial-turners. If you’re caught doing that, you don’t get a Christmas bonus. The dial-turners are getting scared (they promised their family an in-ground pool), and they want to get out of the dial-turning business and get into something safer, with lesser penalties for getting caught. So, the dial-turners, who are organized by the way, start asking for buttons, and set them up.
Back to the real world (getting dizzy yet?), and the same thing is happening. Organized crime is real. Illicit drugs, as an example, have been a nice tidy revenue stream for these groups for some time. But life for drug dealers and suppliers, because of things like the War on Drugs, is getting a little harder (I didn’t say the War on Drugs was completely ineffective). Not impossible, mind you (remember the cockroach analogy?) but harder. Many are finding that health care fraud schemes are just as profitable, without as much risk of being shot by a competitor, and with more limited sentences for convictions. Oh – and for years, almost no-one was watching. So, if you’re a criminal looking for an easier row to how, take a look at health care fraud.
But fraud is only a portion (though a big portion) of the issue associated with the fee-for-service payment system in health care. There is also an embedded fatal flaw in the core idea of incenting providers and suppliers on a volume basis. Through fee-for-service systems, we reward “doing” more, even if the more that is being done is unnecessary, is of lower quality than we would expect or want, or is more expensive than an alternative that may be just as, if not more effective than the more being done.
It’s certainly logical, in any endeavor, to pay for products and services that are both valuable to the consumer/stakeholder and are not readily or easily available/doable on your own. I am glad to pay someone a reasonable amount to do things like repair my vehicle, fly an airplane I’m using to reach a far off destination, or provide my home and my family with clean, running water. These are things that I personally do not have the expertise, time or desire to do for myself, and so I gladly give portions of my hard-earned money to others for these acts and products. The same goes for medical care. I’m happy to provide funds to someone else to help me by providing diagnostic services when I’m ill, provide me medications that are needed for my conditions, or even perform surgery when it is needed.
What is not logical is to establish and then support a system where the services are paid for whether they are needed or not, and no matter the outcome of that service. For example, when I take my car into the mechanic for an oil change, I don’t want to pay for a new transmission if I don’t need one. If I board a plane to Atlanta, I don’t want to find out that I’ll also be paying (extra) for a stop over in Detroit that I don’t need (or want for that matter). And I want clean water in my home, but I would not want to pay the utility company if my water is constantly brown, and makes me sick because of contamination.
The same is true for health care. We want to get better, or, better yet, prevent getting sick. For those services, it is logical to pay. However, if, in the process of “getting better” or “preventing illness” we are subjected to service, treatments or medical products that do not help us along the path to wellness (or actively make us more sick), and we are asked to pay for those things, then we have a problem.
So, by using fee-for-service, we have fraud, which will admittedly be present in any system, but is more prevalent in a system that makes it easy to bill, pays quickly, and has so much volume that it’s easy to slip below the radar. We also have a perverse incentive to drive volume of work versus quality of work. We can potentially, through enforcement efforts, keep fraud in check to a certain degree. We cannot, however, eliminate the fatal flaw in how we incent payment without major overhaul.
We must come up with a system for payment in the health care industry that reduces or eliminates the incentive to just do “more” and replaces it with incentives to do what is “right” for the patient and actually “works” to accomplish our end-goal of health. I actually propose we start at the end of the process and develop backwards. Our end goal in health care is (or should be) to improve or preserve health. So, let’s use health status of a patient as a criteria marker for payment. In other words, pay for medical outcomes.
Instead of paying for services, on a negotiated fee schedule, pay for improvements in conditions. If I am diagnosed with high blood pressure, why not pay my health care provider when my blood pressure goes down? If I am diagnosed with diabetes, why not pay my health care provider when my Hemoglobin A1C is brought into a normal range? Take established and accepted treatment goals, and incent health care providers to help the patient reach those goals.
In the same vein, think about paying primary care physicians based upon the health status of their patients overall, instead of based upon how many encounters they have in their medical office. Instead of “visits” they are paid on “wellness.”
I would suggest we pay handsomely for helping patients reach aggressive goals, and pay very poorly for working at it and yet failing to have patients “get there.” At the same time, to engage patients in their own care/health give them an incentive to do their part. I propose you establish cost-sharing schemes that allow the patient to pay less out-of-pocket if they reach their health goals and more out-of-pocket if they don’t.
Suddenly, you have everyone aligned. You have health care providers looking at how to most efficiently and effectively get people better, or better yet, keep them well. Your personal health is now tied to your financial health. Your person health is also tied to your health care provider’s financial health.
Hold on – we’re going back to our button… No-one knew it, but the bell you were hearing was ringing every time a fire broke out somewhere in America. And your button – well, it turned on the sprinkler system to put out the fire. Well worth the $5, right? But, slowly but surely, with all the extra button pushes (yours, your brother-in-law’s and organized crime’s) most of the homes in America are now flooded. So, realizing they have a problem, the button/dial administration undergoes a radical transformation, and emerges as the fire suppression administration. They recall all buttons. Instead, they offer every family in American $10 a week if they do not have a home fire. Instances of home fires drop dramatically. Unfortunately without the extra button income you have to cut back to 2 peppermint mochas a week (using your new fire avoidance allowance). But fortunately your brother-in-law takes his lovely family, RV and yacking dog home, and the dial-turners decide to investigate widget-making as a new profession instead.
Fraud in health care will never be completely gone. No matter the system in place, someone will find a way to game it. At the same time, not payment schema is perfect, and there will always be some illogical aspects. But, with engaged patients, properly aligned health care providers, and sufficient credentialing (and ongoing audits), I believe the majority of the health care fraud we experience today would be gone, overall health care costs would drop and we’d likely be healthier to boot.
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