Back in the 1980s I was a big fan of HMOs as a way to improve the quality of care and manage costs. All the elements were there in theory; coordinated care, no incentives to provide more care, even physicians on salary so they could concentrate on patients. What’s not to like?
As it turned out critics and eventually patients found a great deal to dislike; so much so that the concept was so watered down as to be ineffective. In the IPA model where physicians were paid under a capitation arrangement (a fixed monthly payment for each patient to cover all the primary care provided), physicians complained the payment was too little. Patients said they were treated as second class citizens compared with other patients. Critics said there were incentives to avoid providing care. Group practice plans we’re criticized for denying necessary referrals outside the plan.
Today we are at it again trying to move away from fee-for-service medicine. Both Medicare and private insurers are attempting to pay for episodes of care and to foster better coordination of care. Strategies include bundled payments, accountable care organizations or contractual payments to treat patients within a budget over a period of time. While the question of withholding care to save money is still with us, there is one big difference this time around. All these efforts are linked to quality measures of some kind; at least an honest attempt to mitigate any effort to avoid necessary health care in favor of financial targets. Whether quality can effectively and accurately be measured in all these settings at the same time-saving money is open to debate.
Will this new effort work, only time will tell. However, new payment systems have a chance only if health care providers feel they are fairly compensated and remain free to provide all the health care they believe necessary. Patients will accept the systems if they don’t feel constrained when seeking care or believe they are on the short end of the stick when it comes to tradeoffs between costs and care provided.
The balancing act between expectations, perceptions and reality in health care is still with us.
- Doctors Agree: Their Jobs Suck, and the Government is Largely To Blame (reason.com)
- The Accountable Care Organization: Think opportunity, not threat (kevinmd.com)
- New health-care incentives create happier Maine patients (bangordailynews.com)