Quality Over Quantity

Last week, the Obama administration announced that it was planning to overhaul the way doctors are paid in America — specifically, to focus payment based on the quality of care given rather than the volume of patients seen and procedures performed. While there are some causes for concern, this proposed policy represents an important, positive shift in the way the American healthcare system works.

Changes in how doctors are paid have been in the works for a while, according to the Washington Post. Before the Affordable Care Act was implemented, insurance networks such as Blue Cross and Aetna were already trying to raise the numbers of payments to healthcare providers that place quality of care above volume in their work. There is no doubt that the trend will continue, with Aetna forecasting its proportion of value-based contracts to jump from 28 percent currently to 75 percent by 2020.

The biggest plus of this system will be a change in the way doctors are rewarded for hollow care. Vox reports that “most American doctors aren’t paid on whether they deliver … improved health.” Under the current system, a doctor’s income is primarily dependent on performing a procedure or prescribing a test or scan. There isn’t merit-based pay: The doctor will be paid regardless of the success of the procedure or whether it actually improves the patient’s health. Obviously, there is a huge incentive to over-prescribe. This plan seeks to change that, especially because doing so will cut down on the approximately $210 billion of wasteful healthcare spending that occurs in this country annually.

These are all good things. But the big question remains to be answered: How does one quantify improved health? A 2014 study conducted by the Rand Corporation and funded by the U.S. Department of Health and Human Services asked exactly that and came up with an unsatisfactory answer. As the study says, “We still know very little about how best to design and implement [value-based payment] programs to achieve stated goals and what constitutes a successful program.” The Washington Post also reported that the study, “which reviewed pay-for-performance models implemented over the past decade, said improvements were ‘typically modest’ and often hard to evaluate.”

When the Affordable Care Act was first introduced, the Obama administration was urged to push for merit-based pay. It didn’t do so and instead put into place many smaller experimental rules, such as penalties for doctors if patients returned to the hospital after a procedure was done incorrectly the first time. It also created Accountable Care Organizations, “larger groups of doctors that band together and take a lump sum of money to care for a specific group of patients, much like what the White House wants lots of providers to do under this new plan.” At Vox’s last count, there were 366 ACOs in various locations across the United States.

However, these experiments favored large healthcare systems and hospitals with many doctors under their wing. Smaller businesses and doctors with private practices could have a much harder time adapting to the system. There is also the issue of patients with chronic conditions and how doctors will be charged for the care afforded to those patients, some of whom might not show measurable improvements in health, if any.

These concerns, added to the fact that the Obama administration wants to institute most of the changes by 2018, could lead to major difficulties in implementation, especially if there is a switch to a Republican-controlled White House in 2016. After the Affordable Care Act deployment debacle, this administration and the Democratic Party don’t have the political capital to go through a similar spectacle yet again.

There is most certainly a need for the systemic changes that were outlined in last week’s proposal. But perhaps it would be better for the country and the healthcare system as a whole if, this time, the major kinks are thoroughly ironed out and not brushed to the side in favor of an earlier rollout date.

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