Reinventing the Square Wheel

My take on "Health Insurance Reform" - Part 1

I've been following many of the discussions about the creation of the so-called "Medical Home," a concept championed by the AAFP as well as the ACP. First of all, the descriptions of the actual model describe precisely what I am already doing:

[P]roviding comprehensive primary care for people of all ages and medical conditions. It is a way for a physician-led medical practice, chosen by the patient, to integrate health care services for that patient who confronts a complex and confusing health care system.

What's currently being hashed out are ways to tweak the payment system, allegedly to adequately pay physicians for doing, well, precisely what I already do. Here is Dr. Bob Centor's bullet point version of the payment debate:

1. Patient care benefits from coordinated care
2. Physicians will provide better systems of care if they receive some compensation for that provision. By this I mean telephone access, email access, etc.
3. Paying piecemeal for telephone calls, emails and the like is not feasible nor practical.
4. A single global fee for all care might discourage patient visits.
5. Combining a monthly management fee - which is meant to pay for all our "extra" time - with a fee for service for visits.

Forgive me, but this sounds awfully similar to the already tried -- and failed -- model known as capitation. Oh no, cry the Medical Home advocates: this time we're talking about paying you for all you do. Uh, excuse me: that's what capitation was supposed to be. Besides, the major reason capitation failed wasn't because the model was flawed but because it didn't pay enough. The other reasons are that so-called "preventive health care" doesn't save money, and the reality that young healthy people will often not see the value in participating with health insurance plans unless/until they need them. Thus, "comprehensive" health insurance stops being "insurance" in the true meaning of the word. But I digress.

The real reason I don't believe the Medical Home model will amount to substantive success is because of the the fundamentally flawed process: people who claim to know what is best for me getting together to decide how I will be paid. In form, this is how Blue Cross and Blue Shield got started in the 1930's and how Medicare came into being in the 1960's. According to the advocates of the Medical Home, it will solve all our problems. That's what they said about BCBS and Medicare, and look how those turned out. Other flawed truisms are that the government has to do something to "fix" the "broken health care system" (I would argue it's the "healthcare payment system") and that doctors cannot accomplish anything without uniting.

Americans -- including doctors -- are capitalist fundamentalists. Those of us in private practice are business owners and entrepreneurs. From an economic standpoint, it doesn't matter that our product is health care. Whatever happens in the ivory towers and smoke-filled back rooms of the policy debates, we are going to continue to make decisions based on what is best for our business, given whatever economic climate and constraints present themselves. Health care employers including large group practices and hospitals will do the same, as they too are functioning as businesses.

Therefore it is my firm belief that things will change in health care payment, although I do not believe that any top-down mechanism -- be it government or privately orchestrated -- will bring it about.