Payment For Performance

Tuesday, 20 February 2007 19:00 Written by Allan Besselink

Within the past few weeks, I've found myself reflecting upon the health "care" system as we know it now. Having been within the physical therapy profession for almost two decades, I've seen trends come and go, and I have watched some things remain (curiously) stagnant. Buzzwords are here and gone, and the cost of health care is skyrocketing nonetheless.

So here's an idea I was pondering recently. It has to do with the payment of services in the medical and healthcare realm. My idea may at first seem unorthodox - and I am certain it will make a lot of people angry - very angry.

As clinicians, we're now inundated with the premise of "evidence-based medicine" and how we have to develop our practice patterns around the breadth of the current literature. Insurance companies threaten us with "we're now reading the literature and we're not going to pay for those things that aren't effective".

Oh my - scary isn't it?

Have you been in the real world lately? Let's see how many pay lip service to the evidence-base. Take a look around you and check the "evidence-based practice patterns" that exist in our health care world. Are the clinical outcomes any better? And perhaps more important, are patients more satisfied or successful with the new level of care? Worse yet, look at who (clinicians) are still being paid for it - and who's making the payment (insurance). Yes, it's those same folks that told us that "they weren't going to pay for the things that aren't effective". We collect outcomes data - rudimentary and otherwise - to serve some minimalistic purpose which, in many ways, gets fully ignored by our peers and our payors.

So here's what I profess.

Let's set up a "PFP" plan - "Payment For Performance". Payors should not hesitate to reimburse ANY clinician that can verify his outcomes AND verify both the patient's return to normal functional status (for that given individual, not compared to an age or gender grouping) AND their ability to attend to their condition actively. In or out of network. If I am a payor, I would gladly pay any clinician to help solve a problem for one of my members effectively and cost-efficiently. In some regards, I think the payors might eventually "buy-in" to something like this.

But ... we then need to look inside ourselves as clinicians. Imagine, if you will, the clinician that simply uses whatever visits have been authorized by the insurance company - until those visits run out. Would they be well-reimbursed in a system like this? Certainly not as well as a clinician who can not only validate his/her outcome but also document a specific return to normal functional activities. I can see the potential resistance to this as I type these words - because it bucks the status quo.

Yes, you'd have a lot of angry practitioners. You're darn right you would. "What do you mean I am not going to get paid for my 12 visits?" Or perhaps you'd see some happy ones - "it's about time that I got paid well for the good work I am doing and my ability to foster an environment of self-efficacy" (and lower long-term health care costs, but I digress).

Do you not find it a tad discomforting to realize that medical care is a long way off from the free enterprise system, one of the only professional categories in the US that doesn't truly practice this? We're so concerned about having health care coverage for everyone in a "socialist medicine" model, yet as we speak, everyone gets paid the same for varying standards of work anyways. Funny how if you're a good auto technician, you make good money - and if you're not, you don't - because eventually word gets out that there are better options that are worth spending the money on. As a lousy auto technician, it is then to your benefit to "up your game" by perhaps learning what the latest techniques are or how to keep the customer happy with their experience.

It's like that in virtually all markets in our country. But in health care, you don't specifically have to prove your outcome or that you do anything any better than anyone else. And that, my friends, is a travesty for the system - and for the consumer.

"Payment For Performance" would be an instigating factor for all of us to "bring our A-game" to a new level - or get out of the profession(s). It would diminish health care costs - both short- and long-term. And in the long run, it would foster a truly free enterprise environment by putting the power back into the hands of the consumer. And how could that be so bad - it IS all about the patient, isn't it?

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