A new patient of mine shouldn’t have been “new” at all.
Three times he visited a primary care practice, complaining of chest pains. And three times he was sent home – without diagnostic testing – with antacids to treat mild reflux.
The fourth time he went to the emergency room, he was thoroughly examined and properly diagnosed with angina – and ultimately underwent heart surgery.
While no physician is perfect, I surmise that this delayed diagnosis had as much to do with cost prevention as disease detection skills. Healthcare payment models that disincentivize costly tests may be eroding the quality of care that patients expect and deserve.
Among the many weighty issues facing lawmakers are a few I consider to be the most significant to the health and wellbeing of millions of elderly Americans: How will we treat our aging population? Who will treat them? And how will we pay for it?
We need the administration and the new Congress to take action – or this multi-faceted predicament will soon overwhelm our healthcare delivery system.
New payment models take their toll
Annually, through 2030 or so, about three million Americans will reach retirement age. And many will suffer – in record numbers – the healthcare problems that often come with age. While we can’t prevent an aging population, we can take bold action to combat some of the challenges they will face.
To do this, we must take a closer look at the ongoing shifts in healthcare payment models, which in some instances, impact the quality and type of care being delivered.
Health care in the United States has been challenged as traditional payment methods – how doctors are paid for the care they deliver – have changed. These major shifts have been driven by health care costs representing an increasingly significant percentage of the GDP. This has led to legislative action through the Affordable Care Act, and increased cost pressure from commercial health insurance companies following Medicare’s lead. Hence what the government mandates significantly changes our healthcare system. This trend is almost sure to continue; in fact, I predict that in less than ten years more than 75 percent of health care expenses will be reimbursed with a form of government-based insurance (Medicare, Medicaid, CHIP, Tricare, Exchanges, Veterans Affairs, etc.)
While hospitals and physicians will – of course – continue to strive to deliver the best care possible, under these new models, they are now financially incentivized to provide care with less cost and utilization of resources. That’s a good thing…unless patient care is undermined as a consequence.
What the payment systems of the future should do is incentivize well-care — meaning compensate providers for prevention, early detection, and disease management. In order to protect the sick and aged, we have the sophistication to use models to compensate providers appropriately in order to avoid adverse risk aversion.
For instance, for many of the most costly and complicated procedures, under some of today’s payment systems, providers are incentivized to focus on patients who are most likely to do well and have a quick and inexpensive recovery. Over time, this could lead to more low-risk case selection and even the denial of care for higher risk patients, especially at under-resourced institutions. Often these higher risk patients benefit the most. Sadly, the older the patient the more likely this is to be true.
How Congress can help
First, despite these varying and serious issues, we must acknowledge that while not perfect, the U.S. delivers the best care in the world for patients over the age of 65. The Medicare system — despite its flaws — has successfully provided high-quality senior healthcare for over half a century.
But we can – and must – do more to maintain and improve the high-quality healthcare that senior citizens (and for that matter, all Americans) expect and deserve. And at a cost that is reasonable and manageable for all. Congress and the Administration can help by ensuring value-based payment models are built on the quality-of-care provided.
What then are the options to deliver high quality care without denying care due to the cost; putting “Patients First”?
1. Eliminate fee for service payment models at the individual physician level. We believe that the Cleveland Clinic model of all physicians being on a flat salary without bonuses means patients get appropriate care, without over treatment or denial of care.
2. Collaborative team decision making. Each patient case should be reviewed by two independent, non-incentivized physicians. Having insurance companies or representatives of government payers making decisions about denial of care because of costs may compromise quality care.
3. Practice value-based care. When a caregiver puts the patient first, we listen to what is best for that individual, what he or she really needs and wants. While we may follow a care path to help efficiency, the best care is always the care that meets the true needs of the patient. If policy makers compensate physicians for the quality time we spend with a patient rather than the amount of paper work we produce, everyone will win.
While provider-sponsored risk can enhance accountability, I remain steadfast in my belief that maximal care for patients must never be compromised. Thus, Congress should carefully reexamine the mechanics of Medicare Accountable Care Organizations (ACOs) as well as whether or not they are delivering on the “patient care” component of their mission. Safeguards to ensure that access to and delivery of patient care are never compromised solely for the sake of cost reduction must be carefully written into ACO requirements.
Healthcare in the U.S. is changing in ways that we cannot entirely foresee. But we have clear evidence that tweaks to value-based payment models and other steps can continue to support our efforts to cut costs – but without sacrificing patient care.
Our President and Congress can make a difference, by implementing legislative measures to ensure that we appropriately and efficiently care for our aging population. I eagerly stand ready to contribute to the debate and call on my colleagues and patients to do the same.
Lars G. Svensson, MD, PhD, is an internationally known cardiovascular and thoracic surgeon. He is the Chairman of the Sydell and Arnold Miller Family Heart & Vascular Institute at Cleveland Clinic.
The views expressed by this author are their own and are not the views of The Hill.