First published on WSJ.com
on Sept. 25, 2016
Having recently proposed [changes at the US Food and Drug Administration](this post) that could benefit all persons who take or will take medications, here I’ll present a simple modification of healthcare payment policies that could yield large dividends, too – in health, in finances, and in patient satisfaction.
The principle is straightforward: pay physicians a bonus for providing continuity of care. In other words, insurers (including Medicare) would pay a bit extra to a physician who sees a particular patient multiple times over a long period, versus a physician seeing the same patient for the first time.
A formula, based on the number of visits and time, would calculate the bonus. For example, a family physician could be paid 10% more when seeing a patient for the 10th time in 10 years. A hospitalist might be paid 8% more for seeing an inpatient 4 times in 5 days. The bonus’s size should entice health plans to modify their scheduling practices. With computers now at the heart of all medical billing, multiple formulae of arbitrary complexity could be defined, even incorporating the diagnosis.
It is surprising that health systems have not to date been incentivized to provide continuity of care, considering all of its benefits.
Pre-eminently, everyone likes knowing their doctor. And doctors like knowing their patients. But, more practically, deeper physician-patient relationships – as the incentive aims to produce – helps physicians practice better medicine, for multiple reasons.
First, it allows physicians to put the patient’s complaint in context. For example, if, by long association, Dr. Smith knows that Ms. Jones is not a complainer, Dr. Smith will take notice if Ms. Jones actually complains of something, even if seemingly minor.
Trust is the second positive from longer physician-patient relationships. A discouraging number of patients do not follow physician-prescribed treatments. A patient who walks into an exam room already having trust in the physician is more likely to adhere to the physician’s treatment – this is simple human nature. Moreover, knowing that a patient will be returning multiple times enables a physician to eschew winning each battle with the patient, and instead follow a strategy to win the war.
Third, and just as rooted in human nature, a patient hospitalized with a serious illness is going to feel better immediately if a friendly, known face walks into their hospital room. This is important because, ultimately, the medical profession exists to relieve suffering, and everyone in a hospital bed is suffering mentally, if not physically.
Fourth, a long term relationship between physician and patient – and the patient’s family – enables the physician and patient to say difficult things at the end of life. Much [expensive] medical care near the end of life is futile, and although physicians know that going in, they will treat aggressively by default. Aggressiveness is fine when all parties agree, but genuine agreement can occur only when openness is full – again, this is human nature.
None of this is news. We all know that trust is earned, and that the root of good medical care is knowing what’s going on with your patient’s body and mind. Indisputably, care today is fragmented.
Would overall healthcare costs decline? It is an experiment worth performing. Improving adherence to medications and enabling more well-informed end-of-life decisions are just two areas from which overall cost savings could come. Large health insurers probably have enough data on which to develop the first formulae.
Ample evidence shows that changes in healthcare payment policies can have rapid, massive influence on medical practice – witness Medicare’s earth-shaking adoption of “value-based” reimbursement. With suitable protections (barring insurers from surcharging long-term patients), incentivizing continuity of care would spread a practice that every one of us would appreciate.