Want to see your doctor without an appointment? You may have to pay a little extra.
No surprises here: financial pressures have an impact on behavior. I don't fault the docs for trying to stay in the game rather than quitting, but if we want better overall outcomes we must continue to push for changes in the underlying paradigm of payment and measurement.
People with significant out of pocket costs may delay care for what they perceive as less important issues – screening, prevention, minor symptoms, routine follow up for chronic conditions.
Health plans trying to keep premiums down may put in place prior authorization policies to reduce unnecessary use of medical resources.
Medical practices with increasing costs due to increased prior authorizations may add new service fees.
Each choice makes some sense when considered in a silo but this adds up to a vicious cycle. Increased out of pocket costs drive people to avoid care until their health is really bad, driving higher costs. Higher costs drive plans to increase pressure on physicians. Increased costs to practices cause physicians to pass costs on to patients, increasing the “only go to the doc when it is really bad” behavior. 'Round and 'round we go.
We must break this cycle.
We want to keep and enhance good primary care. Absent fundamental changes in payment, docs may see administrative fees as their only option, but administrative fees don’t change the underlying broken paradigm. The docs and patients can't change the system alone - plans and purchasers must align payment and measurement policies with the outcomes we all want.
The game changers:
• Reward outcomes not volume: health care payments AND physician compensation must align with outcomes
• Fund the essential work of high performing primary care: primary care payments are inadequate to the essential work of:
o 24/7 access – not just to ‘visits’ but all channels of communication
o Person-focused relationship over time – continuity to a doctor/nurse who knows the patient
o Comprehensive services – expanded scope of primary care services pegged to the needs of the population they serve
o Care coordination – eliminate the silos. The primary care practice is responsible for their patients no matter where they are in the larger health system
• Measure what is important, not what is convenient: don't mistake the means with the ends - shift measurment to outcomes and away from process and technology indicators
o Outcomes are important – risk-adjusted hospitalization rates, ER visit rates, patient experience of care, functional status, total cost of care
o Use the absolute bare minimum of "means-to-the-ends" indicators when outcomes are impossible to measure due to small denominators. Enough with the "33 of these and ten of those with 15 out of the 65 of the following. See the incredibly detailed tables after you pay your substantial fee." The continual piling on of various measurement indicators is not helpful.