xaelia

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"A Massachusetts panel proposed that the state scrap traditional payments to doctors and hospitals for each office visit or procedure, and instead adopt a system where they receive a monthly or annual fee per patient.

The proposal is an effort to control the state's health-care costs, which are among the highest in the nation.

Under the new system, doctors and hospitals would be organized into groups responsible for all of a patient's health-care needs. The groups would receive a "global payment" per patient, which could be adjusted with performance incentives based on the quality of care provided."
From: http://online.wsj.com/article/SB124779934452456083.html.html

Related (includes link to the government report PDF): http://www.nytimes.com/2009/07/17/health/policy/17masshealth.html?ref=health

I envision this generating a strong administrative push to reduce diagnostic testing in the ER to prevent cost overruns on these annual per-patient payments. I also expect an incentive to document every patient with as many chronic illnesses as possible to increase the monthly payout.

The #1 reimbursement should be fibromyalgia.
 

docB

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Yeah, it's essentially a capitated plan. So if under the current system the unintended consequence is to do too much to run up the bill* this plan would incentivize docs to do nothing to save costs which would now be coming out of their own pockets. Evey plan has a perverse incentive.

* I don't buy that docs are doing too much to run up the bills in the current system. I and everyone I know would rather do less and see more patients which would actually be more financially attractive under the current system. We do too much for defensive medicine.
 

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I don't know much, if anything salient on the matter, but why does something like "performance incentives based on the quality of care provided." automatically garner thoughts of Press-Ganey, and whether physicians who do everything right but are still unable to catch someone spiraling down the drain would be looking at less "performance-based" incentive provision than the individual with pre-written Demerol scripts who gets rave reviews from the NAD 11/10 Chest and Stomache Pain x5d crowd.
 

GeneralVeers

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So under this legislation the frequent flier who visits the ER on a daily basis can still come every day? EMTALA requires me to see that patient, but the law will prevent me from getting paid for those extra visits. Great.

Oh well, I guess I can switch to hour-long lunch breaks, and see 1 patient per hour. You've had your visit already this month? Great, you will not be seen by me until I've seen all the "new" patients for whom I will get paid.
 

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Under the new system, doctors and hospitals would be organized into groups responsible for all of a patient's health-care needs. The groups would receive a "global payment" per patient, which could be adjusted with performance incentives based on the quality of care provided."

#1--the death of the solo practitioner or even the independent group. Unless you never consult and you never have a patient that needs a specialist, your patient has to see someone else at some point. At the very least, fee sharing agreements will have to be in place. A specialist may not be willing to be the 3rd or 4th doctor to see a patient after the fee splits. The specialists will have such power over the Primaries, that without an overriding authority (ie, integrated practice group), a primary can't survive. Thus this forces the corporate practice of medicine.

#2--Forget urgent or short notice appointments. There is no incentive to make an extra appointment for a patient who wants to be seen. There is no reward, only risk of being sued and the risk of being late for dinner.

#3--You thought ED waits are bad now. Bust my ass to see a few more patients? Why? A few weeks ago, I saw 4.6 patients per hour. I left about 4 hours after my shift because I had to chart. I did it because I get a piece of my RVUs plus an hourly rate. Give me only an hourly rate and I will see a fraction more than average and I will leave 5 minutes after my replacement comes in. Full waiting room? Boy that must really suck to sit in there.

#4--Proceduralists win again. Dump 'em back to their PCP. Heck the PCP is even getting paid for the illness.

#5--Why try to see the PCP? Just go to the ED. It doesn't cost any more and it is one stop shopping.

#6--What I think is more important. Doctors become employees. While utilization is always reviewed, with a bundled fee, Doctors are beholden to the hospital to get paid. The hospital thinks you order too much? Change or be fired. Too bad the liability is still yours. You think this plan includes meaningful tort reform?
 

GeneralVeers

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#6--What I think is more important. Doctors become employees. While utilization is always reviewed, with a bundled fee, Doctors are beholden to the hospital to get paid. The hospital thinks you order too much? Change or be fired. Too bad the liability is still yours. You think this plan includes meaningful tort reform?
Agree with everything you said. It will certainly not have any tort reform, as Obama has already stated that it's off the table. Does anyone seriously think a corrupt Illinois lawyer isn't going to look out for his buddies?

This proposal is exactly why the Soviet Union didn't work. Sure you can put everyone on a salary, but very few are going to put in extra effort if there's no reward. It's human nature. To think that doctors are all going to be altruistic and treat all patients regardless of reimbursement is to believe in fairies and tree spirits.
 

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When I was in the UK (97), this was one of the problems the A&E centers were facing. GP's got a set amount per year for each patient. When patients had urgent or non-preventive things, they were referred to the A&E center. This caused a sudden increase in volume and wait times.

I don't think the elimination of fee-for-service applies to all specialties. Emergency medicine is one specialty that will continue to receive reimbursements based on procedures and each visit. Likewise, surgeons will continue to receive procedural reimbursement. What is the government planning to do? Pay a surgeon for every patient in America just in case they need their gallbladder out?
 

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What is the government planning to do? Pay a surgeon for every patient in America just in case they need their gallbladder out?
Planning? I don't think anyone is saying this is a well thought out endevor.
 

southerndoc

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Planning? I don't think anyone is saying this is a well thought out endevor.
Yea, I know.

Need that central line because you're lactate is 7? Hmm, I won't get paid anymore to assume the liability of dropping your lung, puncturing your subclavian artery, or causing your bacteremic infection. I'll let the next guy do it.

That borderline laceration would probably look better if I stitch it up. It's going to take time to set up the suture repair tray, suture your lac, and clean up my mess. I don't get paid for my time doing this, and I have a waiting room full of patients. Hmm, let's just put some steri-strips on it. There you go. It should heal (I hope).

Yep, your knee looks like it has some fluid on it. I could drain it and make you feel a lot better, but by doing that, I expose myself to liability if you get an infection or have a bad outcome. Guess what? I don't get paid to take on that risk. Let's just send you to the orthopod. He can straighten it out.

Wow, you had sex with four guys last month and you think you might have an STD. If I give you an antibiotic, you could have a reaction to it. You don't have a medical emergency by my screening exam. You should really follow up with your primary care physician, which you're required to have. Afterall, I get nothing for the possibility of you dying from a reaction to the antibiotic.

(Disclaimer: This post was intended to stimulate discussion and isn't necessarily my viewpoint.)
 

GeneralVeers

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Yea, I know.

Need that central line because you're lactate is 7? Hmm, I won't get paid anymore to assume the liability of dropping your lung, puncturing your subclavian artery, or causing your bacteremic infection. I'll let the next guy do it.

That borderline laceration would probably look better if I stitch it up. It's going to take time to set up the suture repair tray, suture your lac, and clean up my mess. I don't get paid for my time doing this, and I have a waiting room full of patients. Hmm, let's just put some steri-strips on it. There you go. It should heal (I hope).

Yep, your knee looks like it has some fluid on it. I could drain it and make you feel a lot better, but by doing that, I expose myself to liability if you get an infection or have a bad outcome. Guess what? I don't get paid to take on that risk. Let's just send you to the orthopod. He can straighten it out.

Wow, you had sex with four guys last month and you think you might have an STD. If I give you an antibiotic, you could have a reaction to it. You don't have a medical emergency by my screening exam. You should really follow up with your primary care physician, which you're required to have. Afterall, I get nothing for the possibility of you dying from a reaction to the antibiotic.

(Disclaimer: This post was intended to stimulate discussion and isn't necessarily my viewpoint.)
I agree on all those things. I'm going to treat the following patients:

1. Emergencies
2. Things I get paid for.

Since I rarely know people's insurance up front, I assume everyone is going to at least get a bill, and I might collect something. If the government takes over and the payment rules are clear, I'm not doing anything non-emergent unless I'm getting paid.
 

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yeah but if a non-emergent pt comes into your ER, can you really turn them away...i know it sounds nice to say if it's non-emergent i'm not treating it, but sounds like you'll end up in the same liability suit as if you did
 
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xaelia

xaelia

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yeah but if a non-emergent pt comes into your ER, can you really turn them away...i know it sounds nice to say if it's non-emergent i'm not treating it, but sounds like you'll end up in the same liability suit as if you did
You have to do a medical screening exam (which doesn't even have to be done by a physician, necessarily) to determine whether they are in labor or have an emergent medical condition. Unfortunately, the non-objective "severe pain" qualifies as an emergent medical condition, so anyone who says they are having "10/10 pain" (which is everyone) will still need to be treated.
 

southerndoc

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You have to do a medical screening exam (which doesn't even have to be done by a physician, necessarily) to determine whether they are in labor or have an emergent medical condition. Unfortunately, the non-objective "severe pain" qualifies as an emergent medical condition, so anyone who says they are having "10/10 pain" (which is everyone) will still need to be treated.
Motrin is pain management.
 

docB

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Many hospitals around the country are instituting systems to medically screen low level triage patients and then, if they are determined to not have emergent medical conditions and hence not fall under EMTALA, to require payment, copay or proof of insurance if they still want to be treated in the ED.

Joint Comission isn't really the driving force on this it's EMTALA. The question is what to do with patient's with a pain of >5/10 (which is everyone). There is debate as to wheter or not you can document the chronicity of the pain or that their exam is not consistent with 10/10 pain (e.g. "Patient is asleep") and then say they're not emergent. The govt. has tried to keep this vague just like everything else so that they can pounce whenever they decide someone has gone too far.

The real catch 22 begins when you consider that you may be under an EMTALA mendate to "treat their pain" and that giving Motrin to someone who is on Methadone may not fulfill that mandate. At the same time we are coming under more and more scrutiny about prescribing pain medications. So you're damned if you do and damned if you don't. Not a first in medicine.
 

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being as i havent started clinicals yet, and i have never seen an ED kick out a pt for not being truely emergent, you're saying if a pt doesnt have great pain, and isnt emergent (ie i have a cold give me antibiotics) you are not required to treat, just give a physical screening and send them on their way? crazy but i could see this being exercised a lot if there is a pay per pt not per visit system
 

GeneralVeers

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being as i havent started clinicals yet, and i have never seen an ED kick out a pt for not being truely emergent, you're saying if a pt doesnt have great pain, and isnt emergent (ie i have a cold give me antibiotics) you are not required to treat, just give a physical screening and send them on their way? crazy but i could see this being exercised a lot if there is a pay per pt not per visit system
That is correct. The law mandates that all patients must receive a medical screening exam to determine if there is a potentially life-threatening condition. Only after it has been determined that there is no life-threatening condition can you boot the patient out the door.

We never boot anyone with, as generally it's easier to see, treat, and bill for minor visits than it is to do a medical screening exam and kick the patient out.
 

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Why can't there be systems in place where the patient has a stake in this game?

Under this capitated plan, what is to stop the patient from hospital shopping until he gets the MRI of his head? Or go to the ER every other day for his narcotics. What's to stop the crazy mom who goes to the PCP, then to 2 Emergency Departments in the same day until her baby with the viral illness gets the antibiotics that she deserves.

Under the "quality initiative plan" - why penalize the doctor for having a non-compliant diabetic patient? Is it the doctor's fault that the patient doesn't take his insulin? Is it the doctor's fault that the morbidly obese patient didn't lose weight? Is it the doctor's fault that the heart failure patient enjoyed his thanksgiving dinner and now is in acute exacerbation? Is it the doctor's fault that the COPDer who still smokes comes in for an exacerbation?

So patients have rights and autonomy, but the consequences of those rights/autonomy must fall on the healthcare provider?
 

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Hopefully with our soon-to-be single payer system (it will happen within 10 years if the government offers a public plan), we will have nationwide records, which will allow us to access narcotic history.

What? Forgot your NHS ID card? No narcs for you!
 

GeneralVeers

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Hopefully with our soon-to-be single payer system (it will happen within 10 years if the government offers a public plan), we will have nationwide records, which will allow us to access narcotic history.

What? Forgot your NHS ID card? No narcs for you!
We have that in Nevada. It is quite excellent. I can track every narcotics prescription written within the last 12 months for any given patient.

Oh you're out of your pain medicine you say? What about those 180 percocet you had filled last week?

Thank you! Come again!
 

docB

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We have that in Nevada. It is quite excellent. I can track every narcotics prescription written within the last 12 months for any given patient.

Oh you're out of your pain medicine you say? What about those 180 percocet you had filled last week?

Thank you! Come again!
It's a good system but sometimes it lags by a couple of weeks which is the time frame I really care about.
 

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We've got a system in NC to look up people's narcotics.
It takes longer than writing the script for 6 Lortabs though.

Guess how many EDs in MA are going to close? People thought Cali was bad...
 

GeneralVeers

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It's a good system but sometimes it lags by a couple of weeks which is the time frame I really care about.
It's still good for the ones who say "I've been out of my pain medicine for 3 months" when they had a prescription filled within the last month.

You lie to me, you get nothing.
 

Jeff698

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Yeah, it's essentially a capitated plan. So if under the current system the unintended consequence is to do too much to run up the bill* this plan would incentivize docs to do nothing to save costs which would now be coming out of their own pockets. Evey plan has a perverse incentive.
Yep, that's the issue. If you want to control a system, control the incentives. The problem is it ain't clear at all what any given "attempted" incentive will work out as in reality once it is implemented.

Capitated care was a great idea whose incentives, in practice, push physicians to do as little as possible.

The only real way to limit spending is to limit spending. That means rationing. We (Americans in general and politicians in specific) clearly don't have the guts to do this. Physicians don't like being put in the position of saying no to something patient's want but don't likely need.

The only way I can see is to incentivize the patient themselves into limiting their care. The best way I can think to do this is make them pay for a portion of their care. Want the MRI, right now, on your mild knee pain from your minor injury 20 minutes ago? No problem. The MRI is $2,000, your share is normally 20% or $400 but, since you want it RIGHT NOW, that will be 50% or $1,000. What would you like to do? Oh, BTW, my recommendation is ibuprofen and WBAT. Your call.

Take care,
Jeff
 

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The only way I can see is to incentivize the patient themselves into limiting their care. The best way I can think to do this is make them pay for a portion of their care.
Requiring even a nominal co-pay would go a long way toward filtering out a lot of the B.S. that I see on a daily basis. Donate the proceeds to charity for all I care, but have patients take a modicum of responsibility for the cost of the care that they receive.
 

GeneralVeers

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Requiring even a nominal co-pay would go a long way toward filtering out a lot of the B.S. that I see on a daily basis. Donate the proceeds to charity for all I care, but have patients take a modicum of responsibility for the cost of the care that they receive.
Uh-oh, you used the "R" word, a word that has no relevance in our new entitlement society.
 

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What's new about the entitlement mentality? It's been the baseline in society since the baby boomers first hit the stage. We just had a meeting today discussing what to do since the state Medicare has decided it will no longer allow its patients to be seen in the ED for non-urgent complaints. So now I have to do the same level of exam and paperwork to document that this is a non-urgent complaint with absolutely no reimbursement for the group.
 

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Requiring even a nominal co-pay would go a long way toward filtering out a lot of the B.S. that I see on a daily basis. Donate the proceeds to charity for all I care, but have patients take a modicum of responsibility for the cost of the care that they receive.
I remember a study out of Texas a while back that looked at what happened to their ED census after implementing a $1 parking fee. It cut their numbers by (I think) around 25%. For a lousy dollar. It really doesn't take much to make people reconsider that runny nose.
 

GeneralVeers

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I remember a study out of Texas a while back that looked at what happened to their ED census after implementing a $1 parking fee. It cut their numbers by (I think) around 25%. For a lousy dollar. It really doesn't take much to make people reconsider that runny nose.
They rejected my idea for slot machines in the waiting room. People don't want to spend their hard-earned welfare checks on medical bills, but they won't think twice about putting into slots.
 

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They rejected my idea for slot machines in the waiting room. People don't want to spend their hard-earned welfare checks on medical bills, but they won't think twice about putting into slots.
Can the machines pay out Lortabs? Hmmmm. I'll call IGT.
 

Stitch

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It's amazing the impact that the slightest bit out out-of-pocket cost will have on volumes. It just shows how many people are just using it as a free clinic, rather than for actual emergencies.
I was told by a mom the other night that she 'has a right to get any test I want.' She wanted an upper GI series because she was convinced it would prove her kid has reflux just because her other kid had reflux. As it was non emergent, 0200 in the morning and the kid was growing well without much vomiting, I refused to call in the radiologist. She wrote a nasty gram about me, but I don't much care. She left saying 'this place is like a shopping mall. You have radiology right down the hall, and you have lab upstairs. Why can't I just get what I want, it's not like I have to pay for it?'
 

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and that is the problem with society. yeah used to love the people who would call the ambulance, and when we get there say, oh i don't need to go to the hospital, but do you have some tylenol. And when I told them no they would get upset.
 

Jeff698

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What's new about the entitlement mentality? It's been the baseline in society since the baby boomers first hit the stage. We just had a meeting today discussing what to do since the state Medicare has decided it will no longer allow its patients to be seen in the ED for non-urgent complaints. So now I have to do the same level of exam and paperwork to document that this is a non-urgent complaint with absolutely no reimbursement for the group.
What state are you in? Somehow I suspect California.

If so, it shouldn't be surprising. The state is 'balancing' it's budget in large part by forcibly moving a lot of it's obligations down to the city/county level. Like, say, medicaid. You're problem is the perfect example. They know full well that EMTALA says you have to see everyone so they don't have to worry about a backlash of people being refused care AND they no longer have to pay for it.

Great political logic.

Take care,
Jeff