'Primary Care Docs Wade Into Payment Reform Debate' by Amy Whitcomb Slemmer

Last week the American Board of Internal Medicine Foundation convened a four-day meeting on physician payment reform. The title of the gathering was “Achieving Equity, Affordability and Quality, The Indispensible Role of Payment Reform” and it attracted an esteemed group of experts, medical professionals, academicians, consumers and payers. The goal for this forum was to establish a guiding set of principals for national payment reform.

Early in the meeting speakers identified competing pressures that will challenge the adoption of a different payment system. Speakers and meeting participants spoke of the need to maintain patient centered care, patient and doctor autonomy, while being mindful of limited resources in the face of unlimited need. There was near unanimous agreement that most physicians don’t actually know what things cost, and some very funny anecdotes about trying to find out cost information. (One doc asked a lab manager what a panel of tests cost only to be told that the manager was prohibited from sharing that info. When pushed, the manager suggested that the doc couldn’t handle the truth.)

Dr. Harvey Fineberg, the President of the Institute of Medicine gave the keynote address and opened his remarks by polling the physicians in the room about how they are paid.

This simple exercise demonstrated that payment methods were all over the map. Some docs were salaried, some received fee for service, and some were paid under capitation. (There were no concierge providers in the room). As Dr. Fineberg explained each of these payment systems has its own peculiar properties with incentives and disincentives for particular behaviors.

Dolores Mitchell explained that the Special Commission on the Health Care Payment System had recommended the gradual move to a global payment system, which evoked lots of small group conversation about what systems and protections would be needed to avoid unintended consequences for providers and patients.

There was a good deal of conversation about physician salaries and how much money doctors should make. Several speakers pointed out that salary is always assessed in relation to others (the ideal salary being $15 more than your brother-in-law), with little consideration of what the cost is to generate a salary, or what salary represents a barrier or an inducement to join a particular practice area. There was vigorous agreement that primary care must be appropriately valued and paid for in a way that encourages more providers to join the ranks.

This was my first ABIM Foundation Forum, and I was delighted to be among the consumer advocates included in this conversation. Some of my consumer colleagues expressed frustration at feeling like “the skunk at the garden party,” but my small group conversations were eminently more cordial and accommodating. A couple of docs voiced frustration at having patients appear in their offices demanding a particular drug or test – commonly, these challenges arose from patients asking to have an MRI which the doctor judged to be useless. I suggested that these intersections are great teachable moments. If the doctor would have a conversation with the patient that explained that the MRI would yield no useful diagnostic information, and provide no additional insight into the case, I wagered that most patients would withdraw their insistence on a useless, time consuming, resource wasting, test.

Alternatively, I suggested that one thing that would enhance patient trust and improve system credibility would be to have more transparency so that patients could see if there were competing interests at work with referrals or prescription choices. My small group was in vigorous agreement about the role of transparency in a transformed payment system, particularly as this would mean that payers would share more complete information with providers.

I am grateful that the ABIM Foundation distributed the principles that Health Care For All has adopted for our work on payment reform, and I enjoyed discussing some of the immediate opportunities that Massachusetts has to be at the forefront of payment reform.

We discussed coordination of care as an important potential benefit of payment reform and there were some folks who were involved in systems of extremely coordinated care. However, it was helpful to hear from a consumer who has a host of medical conditions that require the coordination of 9 doctors and their support staffs. This consumer pointed out that she is the point of coordination, and that her continuity of care depends on her accurate description of all of her treatment. This is a source of endless frustration, and will not be effective for patients who are less well versed in their own medical conditions.

Health Care For All is cautiously optimistic about Massachusetts payment reform, and we think that engaging, empowering, or activating patients in new and different ways will be the bedrock foundation for its success. We know that in a fee for service system unnecessary care is very profitable care. We also know that many providers are frustrated at not having the time or incentives needed to work collaboratively with their patients in a way that improves outcomes. We think that payment reform and a gradual and deliberate move to some type of global payment offers real hope for improving our system of care delivery.

Doctors have an incredibly powerful role to play in national health reform and in payment reform. Consumers want to partner with our providers to improve our overall health and to improve our health care delivery system. The ABIM Foundation Forum was a terrific step toward that ideal.

Amy Whitcomb Slemmer, Esq.
Executive Director, Health Care For All