Reforming the Dysfunctional Physician Payment System
Presentation by
Charles K. Francis, MD, FACP, FACC
President, American College of Physicians
Good morning and welcome.
We are on the threshold of an almost revolutionary change in the way health care is delivered in this country. This change will mean a higher quality of care for patients, while simultaneously making better use of society's scarce resources.
This change, in its basic concept, is simple. The health care community will put information technology to work to improve the quality of care, institute ongoing quality improvement measures and save money at the same time.
The successful implementation of this effort rests on two key elements.
The first involves the need to fix the dysfunctional payment systems used by Medicare and most other payers. Unless Congress and the administration act soon, physicians will face crippling cuts in the pay they receive for treating Medicare patients.
This reduction will hinder physicians' ability to provide what they most value: the best possible care for their patients. The end result will be medical practices that must either reduce, or else eliminate entirely, the number of Medicare beneficiaries they see.
It also bodes ill for the ability of physician practices to acquire the expensive health information technology systems so vital to bringing about needed changes.
The second involves the need to develop new payment models to create incentives for practice innovation and improvement. These innovations include the use of electronic health records and other types of health information technology. Such technology aims to support evidence-based practice improvement.
You are probably aware that the treatment and outcomes for any specific disease or condition can vary greatly among different sections of the country. Or for that matter, even among different practices and hospitals in the same city.
The use of health information technology will give physicians access to clinical decision support tools at the point of care. By clinical decision support, I mean providing physicians--in their own offices, at the time they are seeing the patient-with immediate access to the most up-to-date guidelines and supporting evidence for treating a patient's condition. Later this afternoon you will see a short presentation from Michael Barr, MD, ACP's Vice President of Practice Advocacy and Improvement, of ACP's own high level clinical decision support tool and how this tool could be incorporated into electronic medical records to support quality improvement. Electronic medical records would also contribute to quality improvement in other ways: for example, a physician treating patients, whether in the emergency room or a private office, could instantly have access to their past medical history.
Congress and the administration should also promote the use of new practice models to improve the coordination of care of patients with chronic diseases, centered on supporting the patient-physician relationship.
Unfortunately, current Medicare payment policies favor episodic treatment of patients with acute illnesses and discourage physicians from investing in electronic medical records. This is because Medicare payment policies are based on the way that care was provided in 1965-not the way it is being delivered today or will be in future.
I have been around long enough to remember what medical care looked like forty years ago. We treated patients only when they were sick with an acute condition. There was little or no emphasis on prevention and coordination. We did our best to provide care based on our own best judgment as informed by medical conferences and journals but there were no reliable evidence-based guidelines we could depend on. We were paid, as we are today, only for the work involved in a specific visit or procedure.
Things are very different today. Patients are treated for chronic conditions not just acute illnesses. We put great emphasis on prevention and management of illness rather than just treating symptoms. Increasingly, care is rendered by coordinated teams of health professionals. Most of us understand that medical care has become so complex that we can't just rely on our own experience and training. We need to have our judgment informed by evidence-based guidelines of care. And we know that purchasers and our patients are no longer satisfied to pay us for how hard we work; they want results.
I'll leave it to my colleague Bob Doherty to explain in more detail how Medicare payment policies need to be changed to reflect the way that medicine is practiced today. He will specifically explain the role that well-designed federal quality improvement pilot programs can play in helping to achieve our goal of better health care quality supported by reimbursement incentives. And he will present an ambitious but practical plan of action to achieve this goal.
I just want to make one crucial point from my perspective as a physician. I urge you to keep in mind the most important element of the health care system. And that element is the physician-patient relationship.
Nothing can take the place of the trust a patient places in a physician that he or she has seen for years. And I'm not talking about trust based on the fact that the person is a doctor. I mean the trust you put in another human being you tell the most intimate details of your life. You give them this trust because you know they have no other motive other than to help you.
And on the physician's part it involves the trust he has that the patient will follow his recommendations and that his guidance is valued.
Nothing can replace the unique knowledge a physician has about his patient based on years of visits and discussions. This doesn't concern just physical knowledge. It's equally important to have a prior understanding of a person's lifestyle, their moods, their likes and dislikes, and a hundred other elements that make every human life so unique and so priceless.
A physician typically knows from personal experience that one patient is extremely conscientious about adherence to a prescribed course of medical treatment. But for another patient, you may know equally well that considerable follow up is crucial to making sure the treatment plan is being followed.
This knowledge will never fit neatly into any kind of database. It can only be derived from the unique relationship that grows between a patient and a primary care physician over time.
If there is one crucial concept you take away today, I hope this is it.
If health information technology helps improve the physician-patient relationship it will accomplish wonders. But if not, the expected gains from such will never materialize. In fact, the practice of medicine will actually have taken a step backward.
Correct implementation is the key to making gains and ensuring they last.
Again, thank you. Now we'll be hearing from Bob Doherty.
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