We are now halfway through a four part series that provides an EPIC solution to health care reform. Thus far, the series has discussed the first two pillars: Evidence and Payment.
Many people have theorized that if universal health coverage makes an appearance in this country, then the level of care and ingenuity of providers (i.e. the brain-trust behind health care) will diminish. Would the brightest minds move away from a career in health care? I would suggest that the answer is “no”. Entry level requirements in many health care provider educational programs are higher now than they were 20 years ago, and I don’t foresee that changing just because we change our reimbursement structure. In fact, I would project exactly the opposite.
Why? Because of the “I” in our EPIC solution: Incentives. Changing the incentives will actually promote having the brightest minds using the best techniques to then earn a healthy living doing what they do best.
In Part 2, I mentioned that part of the problem with our current health care delivery and payment model is that it is built around the wrong incentives. Providers are reimbursed by the number of procedures performed, not by the outcome or concordance with clinical guidelines. Patients are seeking health care, and not disease prevention or health promotion. These factors promote the wrong incentives - by definition.
As it stands, those who provide great outcomes get paid exactly the same as those who don’t. Those who utilize (and bill for) more services earn a better living, regardless of whether or not those services actually have a positive impact on the patient’s outcome. Insurance companies make more money when fewer services are paid.
But good minds have the capacity to see through the inverted incentives. We need to put the onus on the providers and patients – and not the lawmakers – to build a system with the correct incentives for all. Surely if we can put a man on the moon within a decade, we can solve the problems of health care in our country. Let’s take a moment to look at what is being done elsewhere – and learn from it. Right now, we are the only industrialized nation in the world that doesn’t have some degree of universal health care – so either we’re right (and everyone else is wrong), or there is something to be learned elsewhere. Utilize our brightest medical minds to create a system that takes elements from all health care systems and integrates them into something that will work given the current demographics and health status of the nation.
The foundation has to be built upon an attitude of personal responsibility. Start with the patient. Provide some form of incentive for health promotion and disease prevention. Right now, if you are an Ironman triathlete with a pre-existing condition, you probably won’t get health insurance. But if you are a couch potato with plenty of risk factors for heart disease and diabetes, you will probably have some level of health insurance through your employer. Insane! This type of thinking has been driven by the current health insurance model. There has to be a way to build some incentives into the system in order to re-orient people towards self responsibility and the value of competent self care. This may only be done by re-establishing some degree of link between patient and cost. When it hits your pocketbook, it is amazing how quickly your health incentives change.
With respect to the providers, establish a payment-for-performance mentality – regardless of who pays. This is the root of a free enterprise, capitalist society. If you are good at what you are doing, you get paid well – and if you’re not, you are looking for another profession. No, just because you graduated from medical school (or any other health care professions program) doesn’t mean you are entitled to a huge salary. But if you can show outcomes (relative to disease, condition, and demographic), then you should be reimbursed well. We need to return to a quality-based paradigm, not a procedure- and entitled-to-be-paid-for-what-I-did-regardless-of-the-outcome paradigm.
If we do so, the best minds will take on the challenge. They will want to find the best assessments and treatments that produce the best, most efficient outcome. Great minds think that way. And in the process, we will truly establish the best health care system in the world.
Part 4 of this four part series will explore the “C” in EPIC – and perhaps the most important pillar – Choice.
Photo credits: EpicFireworks
"Running Injuries: Etiology And Recovery- Based Treatment" (co-author Bridget Clark, PT) appears in the recently released third edition of "
" by S. Brent Brotzman, MD and Robert C. Manske, PT.
