Tuesday, July 07, 2009

Congressional Pro's to Deform Health Care

Provider payment
Reform for
Understandability and

Now that's a mouthful. With several decades of community work done to improve access to care for the uninsured, Congress looks to a pilot payment program begun January 2009 as the basis for health reform. They also plan to bundle payments for care across health care organizations.

Prometheus is a complex pay for performance effort. News reports justify the scheme as a response to provider "fee for service. " They ignore that DRG's, capitation, and per diems provide incentives to manage care within financial boundaries. Not everything a provider does is paid for by insurers. It's not even close.

But reformers want to step heavily on the financial pedals. Rewards are the gas pedal and penalties are the brake. They are intended to get providers to change behavior. What's the goal?

In this country we already have so many examples of small and large physician practices and hospitals that deliver very close to defect-free care. Our job collectively, particularly on the payer side, is to pay them so it reinforces that behavior every day.

Whoa, hospitals are achieving such performance without Prometheus? What are they doing within current payment systems? They pay physicians a fair salary, give them time to focus on patient care, and have a laser like focus on quality. They do everything possible to focus on the work, not payment schemes.

That's the real answer, sound management theory and clinical practices. It's not "pay for performance" schemes and bundled payments. Incentive pay produced a litany of bad outcomes, ranging from an imploded Wall Street to Rick Scott's Columbia/HCA to widespread stock option backdating over a decade long period. Surely, doctors and nurses are as smart as CEO's.

Managed care and vertically integrated health care organizations were the health care solutions in the 1990's. They were based on the same assumptions as Prometheus and bundled payments. How did that change work? A physician's practice had to reach 40% managed care patients before their clinical behavior changed. Vertically integrated health care organizations fell apart.

Congress should listen to Forrest Gump. Ignorance is as ignorance does. Bribing providers will backfire, as will having organizations compete for a chunk of a bundled payment. Deform is coming, courtesy of America's horrific leadership. America's quality guru, Dr. W. Edwards Deming, might have said, "Will they ever learn?" God rest his soul.

Prometheus tricked the gods into eating bare bones instead of good meat. His punishment was to suffer daily under a God imposed system. An eagle picked out his liver, a dreadfully painful experience. His liver would grow back, only to be plucked again. It's like hope for health care reform, repeatedly picked apart by the beaks of for-profit health care.

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