Sessions and Themes
- Shifting the paradigm: Vikas Saini
- Magical thinking and Modern medicine: Harvey Fineberg
- What makes us do it?
- What will it take to get us there?: Don Berwick
- What are the knowledge gaps in avoiding avoidable care?
- Case discussions
- What are the ethical issues?
- Medical journals and the issue of avoidable care
- The schizophrenic life of the hospital CEO
- A reason to change: Shannon Brownlee
- Social responsibility of physicians: Bernard Lown
- Behavior-changing Best practices
- Global dimensions of unnecessary care: Julio Frenk
- Payment mechanisms and the Culture of medicine
- Choosing wisely and beyond: What are the next steps?
- How can patients help drive the needed change?
A Primary Care Perspective – Allan H. Goroll
Payment Reform for Achieving Reduction in Unnecessary Care
The Primary Care Perspective – Key Issues
Allan H. Goroll, MD, MACP
Massachusetts General Hospital, Harvard Medical School
The predominant system for physician payment in the U.S., Medicare’s fee-for-service (FFS) RBRVS model as interpreted for CMS by the AMA’s RBRVS Update Committee [RUC], has had several adverse, counterproductive effects on primary care:
• Incented high volumes of short visits by paying only for face-to-face care and assigning a very low rate for evaluation and management services
• Compromised time for proper diagnosis, patient education, counseling, and care management/shared decision making (Ludmerer: “No Time to Heal”)
• Reduced the diagnostic confidence of primary physicians, who feel too rushed to make a firm diagnosis and who compensate by resorting to excessive test ordering and low thresholds for specialty referral both for patient safety and for reducing liability risk
• Discouraged prospective new medical graduates from going into primary care due to financial penalty ($3.5M lifetime pay disparity) and poor work environment (the “hamster wheel”), leading to a national work force crisis in primary care
• Depleted primary care practices of the capital needed to implement the teams and technology necessary to achieve current high-performance standards
Needed: Fundamental reform of payment for primary care, including
• Elimination of the “volume imperative,” (i.e., eliminating the predominance of FFS)
• Realignment of payment to support desired outcomes (e.g., achievement of desired Triple Aim goals); if comprehensive care is desired, pay should be comprehensive rather than piecemeal.
• Assuring sufficient financial resources for the necessary teams and technology essential to high-performance practice
• Paying for work that creates value beyond the face-to-face encounter, including payment for care management and population management
• Powerful, validated risk adjustment that protects against cherry-picking patients.
• Incentives for collaborative care with other providers
• Ability to negotiate payment within integrated systems of care to assure payment is proportional to risk and responsibility undertaken and consistent with overall goals