Is Changing How We Pay Sufficient to Transform Our Healthcare System?
Government and private payers are doubling down on innovative payment methodologies as the “cure” for all that is wrong with healthcare in the US. They can’t seem to escape the evils of fee-for-service payment fast enough. The latest inventions of CMS under the MACRA are good examples of how the feds are using payment policy to solve a myriad of problems with our current non-healthcare system. I don’t know if I’m an outlier, but it feels like the feds are throwing out a ton of ideas and hoping something sticks. They are also putting a lot of resources in the alternative methodology that may not address the underlying reasons for quality and cost differentials with other developed countries.
Don’t get me wrong. I’m not nostalgic about the loss of fee-for-service. I’m just not sure that moving to global payment without pursuing other strategies will bring about the desired results. Sometimes it feels like a way to push the problem down onto primary care physicians because we don’t want to face tough policy decisions like:
The irrational pricing for specialty services relative to primary care;
The oversupply of diagnostic services, which seem to create their own demand;
Spending billions on direct consumer advertising of prescription drugs (New Zealand is the only other country that allows it) ;
Excessive administrative costs on both the payer and provider side relative to other countries;
The absence of health planning at the state or regional level;
Relatively low levels of spending on social services compared to countries with much better outcomes.
Just as we don’t value teachers in our society relative to other professions, our current healthcare reimbursement system seems to place a lower value on adult and pediatric primary care than on interventional cardiology. Could we have a policy that we’re going to close the gap in reimbursement over the next ten years between primary and procedure-based specialties so the people who have already made career choices have time to adapt to the change. (Full disclosure, my wife is a Behavioral and Developmental Pediatrician.)
The challenge of increasing spending on social services is even greater even while the evidence that spending on social services seems to correlate with health is growing. Research done by Elizabeth Bradley of the Yale Global Health Leadership Institute shows that most developed countries have greater balance between health and social service spending than the US. A recent paper explored the barriers to evidence-based planning at the state level to improve population health. Having participated in population health planning at the state level, I have seen first-hand how difficult it is to coordinate health and social service policy, given the rules governing different funding sources and the vested interests of those now receiving funding.
I’m concerned that changing payment methodology alone is not the answer and we are forgoing other policy options that could have more immediate and greater impacts on health. What do you think?