• Condition-based payment for colon cancer prevention: Instead of being paid on the basis of number of colonoscopies performed, a gastroenterology practice could be paid for successful colorectal cancer screening of a population of patients. The practice could focus resources on screening the highest-risk patients while eliminating unnecessarily frequent colonoscopies. The practice could also collaborate with oncologists to manage the total costs of colon cancer screening and treatment for a population of patients, so that physicians could be paid more by reducing the frequency of late-stage colorectal cancer treatments through earlier detection.5
• A gastroenterology medical home for inflammatory bowel disease: A gastroenterology practice could receive a single monthly payment for a patient with inflammatory bowel disease instead of fees for individual office visits. The practice would be able to proactively manage care for the patients to reduce the rate at which the patients experience problems. The monthly payment would be adjusted up or down on the basis of the rate at which the patients use an emergency department or require surgery for complications related to their inflammatory bowel disease.6
Physician leadership is essential
Many physicians are understandably skeptical about payment reforms because they have often been designed by government agencies or health plans in ways that impose inappropriate financial burdens and risks on physician practices. However, instead of resisting payment reform, physicians need to roll up their sleeves and work with purchasers and patients to design accountable payment models with the proper balance of flexibility and accountability. Some of the issues that physicians need to help address include the following7:
• How to objectively define conditions so that payment can be triggered by the condition rather than by a procedure, without encouraging overdiagnosis.
• Which complications are preventable and therefore appropriate for a warranty.
• How care processes can be redesigned to reduce costs without compromising patient safety.
• Which patient characteristics and comorbidities require extra services, so that payments can be appropriately risk adjusted.
The time for action is now. The urgency of controlling costs virtually guarantees that some kinds of changes will be made in payment systems; physicians need to take a leadership role to ensure that reforms are designed in ways that can be successful for each specialty. Instead of being seen as part of the problem of high health care costs, physicians should be recognized as leaders in developing solutions that are good for patients and preserve the successful practice of medicine.
References
1. Miller, H.D. From volume to value: Better ways to pay for health care. Health Aff. (Millwood). 2009;28:1418-28.
2. Miller, H.D. Transitioning to accountable care: incremental payment reforms to support higher quality, more affordable healthcare. Center for Healthcare Quality and Payment Reform, Pittsburgh; 2013 (Available at: http://www.chqpr.org/reports.html).
3. Johnson, L.L., Becker, R.L. An alternative health-care reimbursement system: Application of arthroscopy and financial warranty – results of a 2-year pilot study. Arthroscopy. 1994;10:462-72.
4. Ketover, S. Bundled payment for colonoscopy. Clin. Gastroenterol. Hepatol. 2013;11:454-7.
5. Lee, J.K., Levin, T.R., Corley, D.A. The road ahead: what if gastroenterologists were accountable for preventing colorectal cancer? Clin. Gastroenterol. Hepatol. 2013;11:204-7.
6. Kane, S. Establishing an inflammatory bowel disease practice in an accountable world. Clin. Gastroenterol. Hepatol. 2012;10:1301-4.
7. Miller, H.D. Ten barriers to payment reform and how to overcome them. Center for Healthcare Quality and Payment Reform, Pittsburgh; 2013 (Available at http://www.chqpr.org/reports.html).
Mr. Miller is CEO, Center for Healthcare Quality and Payment Reform, Pittsburgh, and adjunct professor, Carnegie Mellon University, Pittsburgh.
