With all the Obama hype, we remained starved for information on what Obama would actually do as President. With this vacuum of information, I’m forced to review articles such as this from Bloomberg which reviews some of the ideas of his economic advisers even though it is unclear how much these really represent Obama’s beliefs. I’m hoping that this article doesn’t fully represent Obama’s thinking on health care.
Pay for Performance
Under a pay-for-performance system devised by Cutler, doctors would be reimbursed not for the services they provide but for the improvements they make to patients’ health. Patients would be encouraged to take better care of themselves through preventive care and comparison shopping for medical cost savings.
“It can help us get past the ideological battles,” said Mark McClellan, who served as Medicare and Medicaid Services administrator and commissioner of the Food and Drug Administration under Bush.
The plan isn’t without problems. Henry Aaron, a health-care expert at the Brookings Institution in Washington, questioned how widely it could be turned into practice, given the difficulties involved in measuring the worth of many procedures.
Costly Software
It’s also costly. Cutler has suggested the government spend anywhere from $115 billion to $156 billion on information- technology equipment and software for the medical industry.
Adding an element of pay for performance might be of value, but only to supplement current payment. It concerns me when this article (which possibly does not accurately represent Obama’s views) states this as an alternative to paying “for the services they provide.” I sure hope they don’t think that payment based upon performance could replace payment for services provided. As the article notes, it is difficult to measure the worth of many procedures. It is also difficult to evaluate how well each physician is performing. A couple weeks ago I received one report, which conceivably might be used to pay for performance in the future. The report totally left out the data on my own patients, and instead extracted data from the hospital on patients I read EKG’s on but otherwise did not treat. The EKG population had much poorer numbers than the patients in my own practice, and needless to say I have a meeting scheduled to complain about this methodology.
At present the software used is both expensive and inaccurate. While this is a technical issue which might be fixed, there are many difficulties in determining payment based upon performance. When I get a new diabetic patient, they are typically out of control, and I wouldn’t mind receiving extra payment for the effort it takes to get their sugars under tight control. In this case, payment for performance would be fairly clear. However, it is inevitable, regardless of how well I care for these patients, that sooner or later they will develop serious problems as they age. When they are sicker, and more difficult to treat, would I receive less pay because having patients with more complications would make it appear that my performance is not as good? Would an Oncologist have difficulty receiving payment because their performance does not appear very good when they have patients whose tumors metastasize? How do you measure performance, as opposed to simply paying for the service, when a patient runs in with the common cold?
I also have concerns about relying on patients using comparison shopping for cost savings. Patients are in a poor position to evaluate the effects of cost. It costs more for me to achieve tight control of diabetic patients as compared to other physicians who might only see a diabetic patient every few months leaving thier sugars poorly controlled. In the short run, such care is less expensive, but there are many benefits to a more expensive regimen which achieves tight control and reduces the risk of heart attacks, strokes, and renal failure.
Payment for medical care based upon fee for service has its problems, but so far every attempt to tinker with the system, from HMO’s to Health Savings Accounts, has resulted in far worse problems. While this article gives the impression that Obama wants to get away with the status quo and promote exciting new ideas, sometimes simply improving upon old ideas that work is the best course of action. While to be conservative might mean to oppose change, to be liberal does not mean change simply for the sake of change.