Having recently proposed changes at the U.S. Food and Drug Administration that I believe could benefit all persons who take or will take medications, here I’ll present a simple modification of health-care payment policies that I think could yield large dividends, too — in health, in finances and in patient satisfaction.
The principle is straightforward: Pay physicians a bonus for providing continuity of care. In other words, insurers (including Medicare) would pay a bit extra to a physician who sees a particular patient multiple times over a long period, versus a physician seeing the same patient for the first time.
A formula, based on the number of visits and time, would calculate the bonus. For example, a family physician could be paid 10 percent more when seeing a patient for the 10th time in 10 years. A hospitalist might be paid 8 percent more for seeing an inpatient four times in five days. The bonus’s size should entice health plans to modify their scheduling practices. With computers now at the heart of all medical billing, multiple formulae of arbitrary complexity could be defined, even incorporating the diagnosis.
It is surprising that health systems have not to-date been incentivized to provide continuity of care, considering all of its benefits.
Pre-eminently, everyone likes knowing their doctor. And doctors like knowing their patients. But, more practically, deeper physician-patient relationships — as the incentive aims to produce — help physicians practice better medicine, for multiple reasons.
First, it allows physicians to put the patient’s complaint in context. For example, if, by long association, Dr. Smith knows that Ms. Jones is not a complainer, Dr. Smith will take notice if Ms. Jones actually complains of something, even if seemingly minor.
This exact scenario occurred 13 years ago, when emergency-room physicians could not decipher my mother’s nebulous symptoms and wanted to send her home. But a physician who knew her resolutely uncomplaining nature interpreted her mere presence in the ER as a serious sign, and demanded a more aggressive evaluation… which disclosed a cardiac problem that, without treatment, was ready to kill her in hours.
Trust is the second positive from longer physician-patient relationships. A discouraging number of patients do not follow physician-prescribed treatments. A patient who walks into an exam room already having trust in the physician is more likely to adhere to the physician’s treatment — this is simple human nature.
Moreover, knowing that a patient will be returning multiple times enables a physician to eschew winning each battle with the patient, and instead follow a strategy to win the war.
Third, and just as rooted in human nature, a patient hospitalized with a serious illness is going to feel better immediately if a friendly, known face walks into his or her hospital room. This is important because, ultimately, the medical profession exists to relieve suffering, and everyone in a hospital bed is suffering mentally, if not physically.
Fourth, a long-term relationship between physician and patient — and the patient’s family — enables the physician and patient to say difficult things at the end of life.
Much (expensive) medical care near the end of life is futile, and although physicians know that going in, they will treat aggressively by default. Aggressiveness is fine when all parties agree, but genuine agreement can occur only when openness is full — again, this is human nature.
None of this is news. We all know that trust is earned, and that the root of good medical care is knowing what’s going on with your patient’s body and mind. Indisputably, care today is fragmented.
Would overall health-care costs decline? It is an experiment worth performing. Improving adherence to medications and enabling more well-informed end-of-life decisions are just two areas from which overall cost savings could come. Large health insurers probably have enough data on which to develop the first formulae.
Ample evidence shows that changes in health-care payment policies can have rapid, massive influence on medical practice — witness Medicare’s earthshaking adoption of “value-based” reimbursement. With suitable protections (barring insurers from surcharging long-term patients), incentivizing continuity of care would spread a practice that every one of us would appreciate.
What thoughts do you have?