Discussions about health care reform tend to focus on payment methods. Critics assert that insurance companies (in concert with pharmaceutical companies and hospitals) are the primary causes of runaway costs. While there is a relationship between payment methods and quality of care, too much time has been spent on the former part of the equation. To reform the American health care system we must begin our analysis by looking more deeply into how care is delivered.

A brief look at a broken model

For many decades we have had perverse incentives built into our system. With a “fee for service” model, doctors are motivated to perform multiple procedures and tests. As insurance companies reduce payments for those tests and procedures in order to bring down costs, doctors and hospitals scramble to make up the difference by increasing the number of procedures performed. This leads to a “cat and mouse game” between providers and payers.

At the other end of the spectrum is “capitation.” Here, insurance companies send doctors fixed monthly payments to care for their patients, regardless of how many or few patients they see. In this case, the doctor is incented to NOT treat. This can increase the likelihood that a patient will receive inadequate care, and that early signs of disease will be missed. This can lead to chronic illness, which is much more labor- and cost-intensive to treat than to prevent.

All of our payment delivery systems now fall somewhere along this spectrum. This includes Medicare, which many see as an example of a successful “single payer” model that simply needs to be expanded to solve our problems. It also includes the more socialistic Veterans Administration health care system, in which providers are paid set salaries, thereby removing the profit motive from health care delivery.

The problem with all of these schemes is that none have managed to control costs or to improve health care outcomes for patients.

Re-framing the problem

We need to shift our gaze from the perspective of the doctors, insurers, hospitals, and pharmaceutical companies to the perspective of the patient. In other words, we need to become “patient-centric.”

The optimal health care delivery system is the one that treats the patient in the most effective manner; the one that gets the best result for the best value. Care must be built around the patient, based upon the condition with which that patient presents to his or her health care provider.

A patient centered clinical model

In this new model, primary care will be provided at a single location. There will be a central intake station. Based upon the patient complaint, they will be directed to an appropriate provider. If a person has back pain, he or she will be directed to a chiropractor, who can both diagnose and treat. The chiropractor can also recommend adjunctive services as needed, from massage to physical therapy to acupuncture. If medicines (such as anti-inflammatories, muscle relaxers, or painkillers) are needed, these can be prescribed by the onsite MD.

If the patient presents with a metabolic disorder, or a chronic disease such as diabetes or hypertension, they can be seen by a physicians assistant, a nurse practitioner or a naturopath. Onsite referrals can be made to nutritionists, meditation instructors or psychotherapists. Blood work will also be done onsite. If medical specialists are required, the patient will be referred off site.

All of the practitioners notes will be uploaded into a common database, so that providers AND patients can have easy and immediate access. This keeps the patient engaged in his or her own healing process and ensures good communication among the caregivers. This also minimizes the chance of duplicating services, and streamlines the referral process.

How will these services be paid for?

The payer–a private insurer or the federal government–will send a bundled fee to this clinic; a bulk payment to treat a particular condition. If someone has acute low back pain, a certain dollar amount will be attached to that diagnosis. If a person presents with early onset diabetes, then a different, determined amount is paid.

Of course, there need to be stop gaps in this system. Back pain can generally be treated with non-medical therapies. But it might also end in spinal surgery. A sore throat might be allergy related, or as dire as throat cancer. Once a condition is determined to require a higher level of care, re-imbursement must be re-calculated.

Similar systems have been put in place in Sweden for total hip and knee replacements and in Germany for hospital inpatient care. In the US, variations on this theme have been instituted and/or piloted in cancer centers (MD Anderson in Houston), spine clinics (Virginia Mason Medical Center in Seattle), and diabetes and heart disease clinics (Geisinger Health System in Pennsylvania). The results have been lowered costs, higher patient satisfaction, and improved outcomes.

But how will this reimbursement be determined?

There will be a specific calculus to determine cost for treatment of specific conditions. The cost must be tied to the objective results and the subjective experience of the patient under care.

Sample factors to be considered might include some of the following:
–How quickly was patient able to get an initial appointment?
–Did patient see the appropriate provider at intake?
–Was the complaint correctly diagnosed?
–Was treatment appropriate and effective?
–How quickly was the condition resolved?
–If patient was out of work due to their condition, how quickly did they return to work?
–Was patient given instructions upon discharge; e.g. exercises, nutritional advice, ergonomic recommendations, etc.
–Was follow up care done, either in clinic or remotely (phone or email)?
–Was the patient satisfied with their care?

Each of the questions above has a dollar value. This is because specific resources must be allocated to provide satisfactory results; e.g., types and numbers of practitioners utilized, clinical organization, pleasantness of environment, etc. Metrics will be used to establish efficiencies and waste.

The clinic that most effectively addresses these questions will generate the greatest patient satisfaction, and attract the most patients.

Beyond the medical model

Because maximum efficiency and best patient outcomes will demand integration of medical and non-medical services—chiropractic, acupuncture, meditation, yoga, health and wellness coaching—there may be some rumbling from within the medical establishment. But we must expand our thinking beyond the strictly medical model. Why use an MD when a lower cost chiropractor can be utilized? Why not have nurse practitioners do primary intake? Medical doctors should take their place in the overall delivery of care for higher level interventions. When we assign the right practitioners to the right tasks, we will see the best value and the best results. Costs will drop and patient satisfaction will rise.

Out of this will naturally rise a focus on wellness and prevention–and that is where the greatest savings will ultimately be found. There will be resistance from interests that profit from disease management–but this radical yet simple approach will help evolve our system from its focus on sickness and disease care to true, “patient centric” health care.

Dr. Ricky Fishman has been a San Francisco based chiropractor since 1986. In addition to the treatment of back pain and other musculoskeletal injuries, he works as a consultant in the field of health and wellness with companies dedicated to re-visioning health care for the 21st century.

Copyright 2014 Ricky Fishman

[email protected] www.rickyfishman.com