Tuesday, September 09, 2008

Paying Healthcare Providers for Performance.

It is interesting that in today there is an article in the New York Times Science Times about paying healthcare providers for performance, because I happened to have just been working on this same topic. The article clearly, and concisely pointed out the pitfalls of paying for performance. I think there is merit and reason to such a promise, but I advocate a much different system. There is the idea of paying for results, which is different than paying for performance, and is also being tested by Medicare. But as usual, insurance companies and Medicare, just don’t get it. Their solutions fall somewhere in the middle, rather than developing proper methods, they like to use the most basic and limited thinking to reach their goals. In my pay-for-results plan, there is your base pay plus two bonuses for lowering mortality rates and improving treatment rates based on certain criteria. There are no payments for treatment guidelines as in the current system, because it contributes to the risks and abuses pointed out the article, such as avoiding surgery for patients at higher risk or even treating patients who are very high risks, as well as starting antibiotics and other treatments before you are clearly sure of the diagnosis. You earn your bonuses for lowering mortality or treating in the most efficient manner, meaning earliest and easiest intervention. Only if you don’t get a good result while not following the guidelines the government has established, would you be penalized. In this way, you can show that you are able to achieve excellent results without blindly following generalized guidelines. The problem with these guidelines developed by the government is not that they’re bad, because they’re not. Statistically, they are driven as the generalized best practice. However, if people were machines, especially mass-produced well maintained machines like computers, this generalization would work a lot better. The problem is, human bodies don’t all work perfectly alike, and medical science is art as well as science as there is so much still to be learned. Therefore, providers for innovative and maintains strict controls to be on top of the situation can probably do a better job than generalized guidelines. However, if you’re not good at what you do, and you are flouting guidelines without showing a corresponding better practice, you’ll not only get worse results but the system will now be in place to penalize you for it. Patients will need to be set up in the two tiers, with the most sick patients being put in the final tier, and will be judged statistically on a separate basis, so as not to skew your results and lower your bonus. This will help to remove the encouragement, not to take on the sickest and most high risk cases.
Since generalization is built on statistical evidence I am quite sure it saves lives in institutions where the creativity is lacking, or the attention is not quite there, where they are understaffed and overworked, so it is not a good idea to abandon them completely. Rather, they should be used as a measurement tool to compare what treatment is being done at organizations that are doing below acceptable limits. For the best institutions they should be used to figure out what they are doing right and how to ultimately make those generalizations even better.
It is important to create a tier structure that takes into account the kinds of cases, the hospitals are taking on. We don’t want to encourage hospitals to shy away from the toughest cases, or those institutions that currently do, and should handle the toughest cases, to worry about how they may skew their results in a negative manner.
Clearly, we need to hold providers accountable. Just as we want people who repair all our homes or cars. We need to understand that unlike homes, cars and computers, fixing people is not an exact science, and everything we need to know is not known. Having said that however, we have a right to expect that our providers are not only well trained and licensed, but are knowledgeable and prepared to practice using established, statistically beneficial guidelines, unless they have a good and experienced rationale to divert from these guidelines.
We should not allow insurance companies and Medicare to start dictating treatment. When the only way for a provider to get paid is by following the guideline of treatment, even when they strongly have reason to believe they can do better than those guidelines, then they won’t, and medical science will not march forward. Insurance companies and the government are always looking for a way to pay out less, and this is reasonable if they can find ways to more efficiently offer the same or more effective care. However, what’s necessary here is the creation of a more comprehensive and multi-tiered evaluation system and check and balance system, to allow providers to do what they do best, yet help them to avoid some of the pitfalls and errors to which many of them are prone.
We can do better. We must not allow insurance companies, nor government, to choose what is easy and expedient. Simple cost-cutting and financial constraints are not going to fix our health care system, nor halt health care inflation in the future, unless we accept the realities that major change must be affected. At the same time, we must preserve what is best about our system, and that is our well-educated provider system, our top-notch research and development system and our cutting edge development of technology in healthcare and related fields. We can do better and we will do better.


Bruce said...

I actually read the NYTimes article you refer to. Your comments are poignant and right on.

LHwrites said...

Thank you.