March 14, 2013 | Healthcare Careers, Patient Relations, Physician Compensation, Practice Models |By Wayne Lipton | If you listen carefully to the pundits, the “pay for service” world in medicine is changing to “pay for performance.” These industry insiders realize that the current fee-for-service approach has real issues and they offer a revised approach as a panacea. While that approach placates some, I tend to be pessimistic about system-wide changes that disregard the newer set of problems that they create.
In reaction to an imperfect world, where there is an economic incentive to perform services that may not be necessary; to practice defensive medicine; and to reduce the overall cost of medical care, there is a clear call to change the methodology of payment. In theory it seems to address a system that has misaligned incentives. However, anyone who delivers care knows that there are two sides to the equation: the provider and the patient.
The What Ifs in Medicine Today
What if you have the sicker patients? What if you have less educated patients? What if you have patients who are not compliant? Moreover, what is performance? No study or measure can be accurately utilized when there are variations in the population served. Consider that insurance companies in the past that have tried to select carefully those people who they insured; eliminating people with prior conditions was a standard practice. In addition, careful selection of a population that you serve can create better outcomes. In other words, performance can be manipulated by selection.
While there are a handful of legitimate measures of good performance, they are few and far between. And some of those measures are driven by cost alone.
Then, there are additional challenges to the concept of outcome-based compensation. How do you pay for performance when performance is moving toward the team approach to care? It makes the system more responsible than the provider. Who then makes the decisions?
What about those surgeons who take on more complicated cases? Does their outcome data reflect their quality? I am told by some physicians that when they choose for themselves or their family members, they look for those physicians who do some of the tougher cases, because they are the best. I am not sure that the quality data on those surgeons puts them at the top of some list.
I am not a physician, but I can see that performance is elusive when the universe of patients is not homogeneous. But there are other ways to measure performance — ways that are easy to gather, analyze, and utilize. I contend that a significant measure of performance comes from our consumer-based society, that is, patient satisfaction. Therefore, one measurement of performance can be found in concierge medicine, where membership is directly related to patient satisfaction.
Hybrid Concierge as a Quality Indicator
I am not making the case that concierge physicians are better physicians than those in other practices. Some are and some are not. It’s also worth noting that concierge membership is not only dependent on patient satisfaction. There are many factors that come into play on the total membership in a concierge practice. Yet, in joining — and staying with — a concierge program, the patient is ultimately the judge of how a physician performs.
All this uncertainty about performance measures is why I like the hybrid model of concierge care, where individuals can make decisions and elect to participate or not in a controlled environment. In full models of concierge care, the patients make their decisions to participate largely because they do not want to consider leaving their physician and moving to another provider.
While there are providers who are well suited for either approach, the hybrid model is by nature more patient positive — the patient chooses whether to pay for the enhanced services of the concierge program or to remain in the traditional practice. What better testament to a physician’s quality than a patient who will pay extra for his or her services?
Continuing the Search for Quality Performance
In a recent interview, a prominent physician was asked about this issue of quality vs. quantity. He replied that because he was salaried, he was above the fray. I laughed thinking that his salary was probably “performance-based” and by that I mean he was incentivized to generate income. The trick is to manage to incentivize productivity while not promoting excesses. If we all knew how to do it, it would be done already.
What are your thoughts about the “measures” of quality in the current environment? Is there enough attention on selectivity? Is there a voice for the consumer in the current or newly devised performance based criteria? I look forward to your comments.