From 1969 until 1978, my parents lived in England, and my mother worked for the NHS in a hospital human resources department. I was talking with them last week about some of the reform ideas for physician reimbursement, and how you get around the problems presented by bundled payments and physician salaries instead of fee-for-service payment systems (ie, cherry picking on the part of physicians, undertreatment of serious problems, etc.)
I am sure that the NHS has changed over the years, but my parents described how it worked in the 70s. Basically, every resident had a doctor. If you moved from one part of the country to another, one of your first errands would be to pick a new doctor. You could choose whomever you wanted, as long as that doctor was currently accepting new patients (all of the doctors had a cap on the number of patients they could have at one time). Then the new doctor would alert the NHS that John Doe was now his patient, at which point John’s records would be sent from his previous doctor’s office to the new one. And the NHS would begin paying the new doctor to care for John Doe, and stop paying the old doctor.
Doctors in the system would get a specific amount of money for each patient on their roster, regardless of whether they ever saw the patient or not. One patient might be very healthy and go to the doctor every few years for a checkup, but the doctor would receive the same amount of money for treating that patient as for treating another who needed constant care for a chronic illness.
I have heard lots of ideas on this subject, and have seen doctors who are offering concierge-style care (including some here in Colorado) where patients pay a set dollar amount each year to cover whatever care they might need. Obviously our reimbursement system is far more complicated that a single-payer setup like the NHS; we have hundreds of different health insurance companies reimbursing doctors and hospitals for care. But what if our doctors were reimbursed for our care regardless of whether we needed to see them or not? I have a doctor I see for well-woman exams. I consider her to be “my doctor”. But she only gets paid for being my doctor if and when I make an appointment to see her.
Would paying doctors for the total number of patients they have provide an incentive for better care, and particularly for better prevention of chronic illnesses? Not to discount the altruistic motivation that doctors have, but our current system rewards them for having sick patients. A patient with diabetes or heart disease is a lot more valuable to a doctor than a healthy patient, because our doctors only get paid when we need to see them. If doctors were paid for having healthy patients, would they be more inclined to focus on things like weight management, diet, exercise, stress-reduction, etc…. all the things that we know can lead to healthier lives but which don’t currently lead to incomes for doctors?
The problem with concierge-style medical practices now is the relatively large retainer fee that patients have to pay in order to join. It’s really only available to those at the top end of the income scale, and generally not covered by health insurance. But maybe the idea should get another look. Maybe we should be looking at the idea of health insurance companies reimbursing doctors for keeping patients healthy, rather than just caring for us after we become sick.
