As many of you know, I am a fan of bundled payments. Many folks equate that to capitation, where doctors take on the risk of defined payments to care for a panel of patients. Bundled payments are not capitation. Capitation assumes all patients represent the same risk.
Bundling models that pay for disease with profit potential threaten the delicate fabric that is our delivery system. A delivery system that focuses, and pays for, individual success without regard to big picture outcomes. We pay for vertebroplasties, an individual success, without consideration of the big picture.
Doctors and hospitals have never been in the business of communication and collaboration. They go about their day, doing their own thing, practicing what they know, living in their own little bubble of practice, and as a result, the patient is bounced from being one person's problem to another.
How many times have you as a patient asked your doctor a question and that doctor said, "That's not my area". You'll have to talk to your primary care doctor or your cardiologist or your pulmonologist or your surgeon. How many times has a lack of communication lead to duplication of your evaluation needs. How many times have you waited for days trying to get answers, only to show up in the ED with decompensated illness.
The lack of communication in the practice of medicine is staggering. As a hospitalist, I find it nearly impossible, at times, to contact physicians who have very relevant plans for my patient in front of me. And I have no idea what they are thinking. I may round at 10 am, they may round at 5 pm. I have no idea what the plan is until the following day. Delayed workups. Delayed discharges. Delayed communication.
Who suffers? The patient. The doctors, the hospital the pharmacy, they all get paid no matter what happens.
What if we practiced in a system where you surrounded yourself with people who's financial success was entirely dependent on all the players in the team? What if the hospitalist made more profit by better communicating their thoughts to the pulmonologist or the cardiologist? What if the cardiologist made more money by preventing the hospitalist from ordering another echo that was just done in the office three days ago? What if the surgeon made more money by preventing a complicating DVT by allowing the hospitalist to order VTE prophylaxis instead of assuming "none of my patients get DVTs"?
What if the hospital's bottom line was dependent on how good the team of doctors, nurses, NPs and PAs got a long and how well they used evidence when available, and best clinical judgment when evidence was lacking?
And what if the bottom line of all the players was dependent on providing high quality care in stead of more care?
That's the vision of PROMETHEUS, which stands for Provider payment Reforms, Outcomes, Margins, Evidence, Transparency, Hassel-reduction, Excellence, Understandability, Sustainability.
Who wouldn't want that?
In the current model I practice in, I plug away, day after day, marking my billing sheet, trying to decide whether it qualifies for a low, medium or high complexity follow up visit based on complicated and archaic rules that add nothing but waste and inefficiency to the bottom line.
What if I got paid to take care of patients and got rewarded for providing the highest quality care I could? The incentive for me is not to do more, but rather to do what I'm doing well. I can live with that.
The only doctors that can't are the bad doctors providing bad care, or the pretend doctors ripping off the Medicare National Bank, under the pretense of practicing quality medicine. Take away the incentive to do more, and pay well for providing quality and you'll see doctors, nurses, and hospitals transform themselves into lean, mean quality machines.
You don't need The Joint Commission telling you to document LV function in heart failure patients. . You don't need doctors submitting PQRI code 4073F-2P indicating they didn't write for aspirin on discharge for their stroke patient because the patient refused. All you need is to hang the money in front of their faces and let their quality guide their decision making.
If as a patient I had the opportunity to be doctored on by a fee for service vs a bundled care model, knowing what I know about how health care is delivered in this country, I would choose a bundled care model every time.
I think doctors leave a lot of quality on the table. You may do your job well as a family medicine doctor. You may do it well as a cardiologist or a gastroenterologist. You may be an excellent surgeon. But your patient does not belong to you. Your patient belongs a team of doctors, nurses, and hospitals. You are but a fraction of the care they require. And what you do in your bubble does not matter if everyone else, as a whole, fails to provide their end of the bargain. For you to succeed requires everyone to succeed. That's the beauty of bundled care.
You can no longer pretend that your job ends when you sign your name at the bottom of the chart. If you want to get paid, you make it your job to be a team player. And that is just fine with me.
