Breaking The Fee-For-Service Addiction: Let’s Move To A Comprehensive Primary Care Payment Model
With much fanfare earlier this year, the Obama administration announced an aggressive goal to process half of all Medicare payments by the end of 2018 through alternative payment models as opposed to traditional fee-for-service (FFS). Primary care is one of the most urgent sectors needing such payment reform. As Bob Berenson succinctly put it, “Fee-for-service, the predominant physician payment scheme, has contributed to both the continuing decline in the primary care workforce and the capability to serve patients well.”
Unfortunately the alternative payment models for primary care currently offered or being proposed by Medicare involve additional payments on top of fee-for-service. Like an addict, we seem unable to go “cold turkey” and instead insist on just a little of our drug.
But this approach is bound to fail. If we truly want to move to a value-driven world and support a value-based payment model, we need to be willing to drop fee-for-service entirely.
Primary care fee-for-service only pays a doctor for a certain set of discrete activities—largely confined to doctor sick visits—which are tiered by means of an arcane coding system counting very discrete micro tasks, such as how many organ systems a doctor examines, or what questions a doctor asks a patient about the quality of their symptoms.
This encourages every health care issue or question to become a doctor visit (because that is paid for), and for the doctor to do most things instead of others on the team (because that is what is paid for). It leads to reactive care (since thinking of a patient not in front of you isn’t paid for), and leads to framing the job as taking care of one patient at a time, like a never-ending series of widgets on an assembly line.
