By Melissa Gerdes, M.D.
TAFP President, 2010-2011
Adequate payment for primary care health services has long been an issue for family medicine. The absence of adequate payment has affected our specialty in numerous ways, including forcing physicians to see too many patients too fast, causing student interest in family medicine to decline, and leading practicing physicians into non-clinical careers. This migration of physicians away from family medicine has a negative effect on the public and our patients. According to the Commonwealth Fund, countries that have a lower proportion of primary care physicians to patients have populations with higher morbidities and poorer health outcomes.
Our current payment system is volume-driven, where physicians are paid more for doing things to patients than for doing things for patients. Research shows that doing more things to a patient does not automatically result in improved health outcomes. In fact, such practice very often results in worsened health outcomes. How do we migrate away from the volume basis?
Many answers to this question are being debated at the national and local level. Some options have been tested and have failed already. The leading ideas include pay-for-performance, comprehensive care payment, episodic payment, and shared savings. Many others abound. How does today’s family physician make an educated choice about which of these new payment systems, if any, he or she should engage? Over the next several months, your Academy will explore the various options.
Many physicians fear we are returning to a dreaded payment model: capitation. Current thinking on payment reform, however, is vastly different from the capitation of the 1990s. Twenty years ago, capitation was a financial-risk term. Today, payment methodology ideas are based upon concepts like quality, service, efficiency, and collaboration. Emphasis is on episodes of care, diagnoses, and the degree of difficulty in caring for individual patients. Focusing on these care aspects improves health outcomes; thus, care has higher value because better outcomes at lower costs are delivered.
Current payment reform ideas represent only partial solutions to the payment problem, however. For instance, under federal health care reform, primary care physicians get a 10-percent increase in payment. But these ideas do not address the true problem with payment, which is the fragmented and disorganized health care system. Broader concepts like clinical integration and accountable care organizations have emerged, but while they may improve care coordination and mitigate escalating hospital expenses, they will probably do little to improve payment for the average family physician.
Perhaps jumping to full system reform is just too much. Total reform of the health care delivery system represents massive cheese-moving in an industry that historically spends 17 years adopting new practices into daily usage. Are we doomed to receive only Band-Aid solutions, then?
The discipline of family medicine has actually tackled this question with its patient-centered medical home concept. While the PCMH has definitely proven to improve patient perception of health, provider job satisfaction, health care quality, safety and outcomes, and to reduce the total cost of care, the PCMH does not integrate the entire continuum of care (what the ACO structure hopes to do) very well. It is upon us, family doctors, to continue being leaders in this area. In the pursuit to improve our patients’ lives, we need to reach out to the other components of the health care delivery system (i.e. specialists, hospitals, rehab facilities, home health) and form collaborative relationships for better quality, safety, and experience. Then we will create an integrated system which provides value. Higher value inherently includes cost efficiency, and only then will payment reform be achieved.