Advocates for Evidence-Based Health Policy Speakers
Coordinated Care: Show me the money!
Policy makers are scrambling to find ways to reduce the cost of health care. One mechanism, converting a fee-for-service system to a prospective payment system, faces uphill battles at home and abroad.
Proposed changes in health care delivery and financing, such as accountable care organizations and bundling of payments, sound great in theory: improved coordination of care for patients, teamwork by physicians, increased quality of care, and decreased costs. It makes patients and policy makers want to chant “kumbaya”. However, these payment structures are so far from the current reimbursement system for most physicians, the actual implementation of these systems seems like something that will only be discussed in theory. Administrators and physicians alike, who are used to thinking about reimbursement based on individual services provided, cannot seem to imagine making such a drastic transition in their own hospital or community, let alone in their own income.
A recent study attempts to quantify this reluctance of physicians to join coordinated care systems by measuring how much more physicians would have to be paid to willingly switch from a fee-for-service system to a system that has various aspects of the less autonomous practice style of coordinated care. This study surveyed 171 Swiss general practitioners, asking questions about physician preference for their current practice status quo as compared to a situation where multiple practice variables, including income, were adjusted. Thus, the researchers were able to assign a monetary value to each of these practice variables. The variables studied were considered to be aspects of a coordinated care system, namely shared decision making (with patients), critical-incident reporting, use of treatment guidelines, and peer quality assurance initiatives. Swiss physicians are currently faced with this actual choice in their practices, as they have the option of being reimbursed in a fee-for-service system (as about 90 percent of them do) or joining a coordinated care plan.
Put plainly, physicians in this study responded that they would have to be paid an increase of an equivalent to $3,380 (US dollars) per month, or about 25 percent of current income, to adopt these practice variables. Specifically, physicians in this study would require increased income to use treatment guidelines and shared decision making. The responses for critical-incident reporting and peer quality assurance initiatives showed no significant preference as compared to the status quo. When asked directly, the physicians reported that they would switch from a fee-for-service system to a coordinated care system if their income increased by at least 16 percent.
A previous study by the same authors showed that consumers would also need significant savings in premiums to willingly switch from fee-for-service insurance to coordinate care plans, which include a more limited list of available physicians.
Based on the current average annual cost of health care per Swiss patient and projected cost savings by using the Swiss coordinated care systems, the authors conclude that the savings would not be enough to cover the necessary increase in physician income and decrease in consumer premiums to have physicians and consumers willingly switch to a coordinated care system.
Commentary
Although this study concluded that the cost savings produced by coordinated care systems would not be enough to cover the increased physician income and decreased consumer premiums, they also pointed out several factors that were not taken into account that would likely make this system work. For example, only mid-career physicians were studied, who are much more likely to prefer the status quo as compared to new physicians. Moreover, coordinated care systems usually come with many desirable characteristics in the physicians’ eyes that would likely decrease the amount of additional income necessary (such as less liability risk, fewer work hours per week, less on-call time, and increased quality care for their patients). With these factors considered, coordinated care systems may produce enough cost savings to be able to afford to persuade both physicians and consumers. Overall, this study brings up an interesting point and predicts a mechanism by which to effect gradual change in the health care system of the United States: just show physicians and consumers a little more money.
Lisa Maurer, MD