Paying Doctors for Better Care

Should doctors be paid in accord with how often they treat you or how well they treat you? The answer presumably is a bit of both. Yet the current fee-for-service reimbursement systems used by Medicare and other insurance programs perversely reward doctors for the volume of services they provide and pay little or no attention to the quality of those services.

Indeed, a doctor who botches a surgical procedure, diagnostic test or drug prescription and then has to follow up with corrective action actually profits from his mistake. He gets paid for the botch-up and then again for mitigating the mistake.

Thus it is salutary that the last Congress, in its waning days, passed legislation that takes a modest step toward the goal of paying doctors based on the quality of their treatment. It authorizes Medicare to pay doctors a small bonus if they voluntarily report data on the quality of their care, like whether they prescribe recommended medications to heart attack victims or examine the feet of diabetic patients. If Congress decides to move the program forward, such data might in time be used to reward doctors who practice the best medicine.

Even this first step had some critics accusing Congress of trying to impose federally regulated “cookbook” medicine. But the notion of pegging reimbursement to performance has strong support from leaders in clinical and academic medicine, provided it is done carefully and in collaboration with credible experts who know good medicine from bad when they see it.

More than 100 pay-for-performance programs already exist, sponsored by health plans, employer groups and Medicare. Many take a graded approach: first paying doctors to report treatment data, then paying extra if they follow professionally derived standards of care, and finally paying more if they achieve successful outcomes measured, for example, by patient satisfaction or by keeping people healthy enough to avoid hospitalization.

Patient advocacy groups like AARP and the Medicare Rights Center favor the approach. Some medical societies, like those representing anesthesiologists and thoracic surgeons, have been working on their own quality standards. A 2004 poll found that a large majority of practicing physicians supported payments based on quality of care.

There is a clear need to improve the quality of care in a medical system that despite excellence at the very highest levels permits an alarmingly high rate of medical errors that harm tens of thousands of patients and drive up costs substantially. We can only hope that this is a real reform in the making, not a passing fad in the endless struggle to improve the health care system.

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