Considering North Carolina’s gerrymandering, voter suppression, racism and other anti-democratic history I hold out little hope for this.
19
@Sandy Telander Tell that to the black officials elected in majority-white districts, cities, and towns.
3
Back to the future!
Nixon signed a law in 1970 in support of HMOs which paid groups of doctors to provide all health care needs for employees of the big employers covered by Federal benefit rules, plus provided funds to for groups of doctors to create HMOs. No fee for service in these HMOs, nor insurance companies, (other than reinsurance for big risks of the chance of several expensive cancer cases or accident victims in one year).
I picked the Matthew Thorton Health Plan as soon as I moved to NH in 1980, and got great care, even as more and more of my peers switched to it. of the employers under Federal rules, the majority picked the HMO over the then not-for-profit BCBS, and the half dozen other insurers. the HMO grew rapidly during the 80s, as did those in Massachusetts covering peers who lived south of the NH border.
Then Congress effectively outlawed HMOs, forcing fee for service paid by a distinct insurer to be "fair" to higher priced for-profit insurers trying to compete for employees picking health benefit options each year at open enrollment.
Since the 90s, economists have been arguing health care should be more like shopping around for a car, because after all, everyone buys a car by shopping for an engine, four tires, seats, lights, radio, body, transmission, etc, because everyone knows relying on car engineers to pick the best combination of parts for the best transport option is socialism.
Time to reverse the destructions of HMOs.
7
It seems to me that this is similar to a method that was tried out in the early '90's and which failed. It was called "capitation," and might have had a narrower base than what NC is proposing. Capitation proposed "risk sharing" between dr. and insurance companies. If a patient did not improve on several parameters and/or had too many appts., the doctor lost money.
Now, it does not take deep thought to realize that this makes the doctor a hatchet man or woman. Treatment plans will be shortened and longer term treatments will disappear whether they should or not. The doctor might choose not to treat conditions if it comes out of their pocket.
Maintenance of health involves two people: the doctor and his/her patient. Payment for health care also involves two people: the patient and the insurance company. Any doctor knows that he or she can only do so much. Patients choose to an extent if and how they are going to be healthy. If a patient is living in an unhealthy manner, the doctor's efforts will fail. Why should the doctor be punished financially?
I practiced psychiatry in many different venues for 36 years. Trust me, patients do not easily come to see a psychiatrist. No-one needs "friends" that badly. I suspect that patients also do not come easily to a primary care doctor. They come because they need to,or b/c they perceive a need.
This is why patients must bear some of the financial responsibility. Insurance companies should continue to contract w/ patients only.
6
This effort is doomed because the standard American diet of double cheeseburgers is killing us.
Until Americans change their diets, healthcare in America will not change.
That and the fact that our environment is polluted. Plastics and long carbon chain molecules saturate everything.
Fracking fluids are in our water supply, competing against lead.
Unless Americans clean up both their environment and diets, you cannot expect anything coming out of the healthcare industry except outrageously high medical bills.
Oh, BTW. You can except nothing but resistance from the healthcare industry to fix either environment or diet because they’ll go out of business otherwise.
7
Humans are born to age and die. Do patients who fail, even after being diligent, share guilt and remorse with doctors about their weaknesses? Are doctors in complicated cases with more than one chronic diagnosis made to feel like a failure time after time?
2
"North Carolina is also taking on health-related risks in a person’s daily life — like access to food, housing and transportation. The Trump administration has approved the state’s plan to spend $650 million of state and federal funds for pilot projects to address these so-called social determinants of health."
Thank goodness someone is finally taking the factors impacting health so seriously. How many states, I'll tell you because it's what I do, are linking transportation to health and economic opportunity? Only one other state even officially acknowledges the links (Maryland). In the meantime, the comments here are either constructive discussions of the merits of what North Carolina is doing or, as is more typical, an opportunity to demonstrate the bigotry of the commenters toward a diverse state with almost 11 million people. Thanks for the first group. The second group needs to get out more and spend some time in their own backyards before throwing stones.
6
“The idea is not new.” No kidding! Hundreds of years ago, Chinese medical practitioners were chosen by their patients by the number of lanterns hanging on the practitioners’ porches. The lanterns represented patient deaths.
4
Just like the rest of America. What we are witnessing is a national problem. In Connecticut, the poor and people of color are segregated to the poorest cities which in turn lack the resources to provide residents with a decent education, much less the financial resources to cover the differences in health care. A person in Hartford is not going to get to see the great doctor in West Hartford (if they can even get there) because they aren't white and rich.
1
Major problems for older adults are AFib associated with heart attacks and strokes, breast cancer for women, and prostate cancer for men. Healthy living doesn't prevent or greatly reduce these. It may help in recovery. So the NC program addresses some problems, it is hard to see how it can have a major impact.
2
@Bill R The major causes of death in America are almost entirely related to lifestyle. Healthy living would VERY MUCH prevent or greatly reduce morbidity and mortality from these causes.
3
This well-intended but ultimately flawed approach will fail. The reason is simple: the poor people have no skin in the game, i.e., no incentive to be healthy. In a belief-based place like NC (another big red state) where tobacco farming is an acceptable indutry, expecting most people to embrace change is entirely unrealistic. For example (one of thousands), "controlling" type 2 diabetes with more visits and lots of insulin in an obese, sedentary 63 year old woman on welfare is little more than a band-aid; making massive dietary changes--like stop drinking soda, eating pork rinds, and visiting McDonald's every day for a Big Mac--is what is needed to stop diabetes--and that "sale" doesn't happen even with millions of doctor and nurse practitioners visits. "Primary care" has been a failed model in this nation and it's false hope to believe it will work any better with this baby carrot approach. Sure, there will be a few, anecdotal "saves" that the recipients of this money will point to as a "success." This will be enough to keep pumping in money into this losing battle.
3
@JCX Did you even read the article before posting?
"North Carolina is also taking on health-related risks in a person’s daily life — like access to food, housing, and transportation. The Trump administration has approved the state’s plan to spend $650 million of state and federal funds for pilot projects to address these so-called social determinants of health."
3
This has been tried and tried again and it will fail to reign in health care costs. The reason? Utilization is not the primary (or even the third or fourth reason) health are costs are high in the US.
When I was a health care exec in Chicago in the 1990s, we built all kinds of programs like this. We paid lots of additional monies to primary care physicians and medical groups for better performance. They actually improved the measures we put in place such as A1C levels, hypertension and lipid control but it had zero impact actuarially on total costs.
Why? Well the reason the US health care system costs so much is simply we pay more per unit of service than the European and other OECD countries. It explains almost all of the variance.
This is just another ploy by the health insurers like BCBS of North Carolina to avoid the real problem. Hospitals in the Triangle area have operating margins in excess of 10%. The same is true in many many markets such as Indiana where insurers pay 3 to 4 times Medicare rates and also have huge profits.
This comes mostly from "monopoly rents" where huge vertically integrated health systems have monopoly power.
When the next health care debate comes - and we are already seeing this - the hospital and managed care industry will use every way possible to convince Americans that any change that impacts our high prices is "socialism" and will kill us all. Nothing could be further from the truth.
17
@Mike Well said!
Dr. Ashish Jha at Harvard has documented what you point out about the high prices we pay for heath care services compared with other high income countries. See JAMA.2018;319(10):1024-1039. Yet "utilization rates were largely similar."
I looked at the impact of BCBS of Massachusetts' Alternative Quality Payment scheme -- similar to the one described here -- on physician behavior in the Boston area in a report published in MedPage Today. Residency training directors were candid on the record in describing modifying practices to reach the "outcomes" goals which were really about process than true patient outcomes ie getting to a target BP by checking it repeatedly in December.
3
A physician can only be a guide to keep one healthy.The job of KEEPING healthy is totally up to the individual.Health maintenance is a personal endeavor.
6
@Jai Totally. See my Comment. I'm confident NYT readers won't give this lots of Recommends, however, because they want to believe that "health care" is a right. With this belief system, health care can be consumed in unlimited amounts, and somebody else will pay for it.
3
This sounds like an enlightened approach, but I am concerned about the pressure on these health organizations to keep there success rates high. Will this mean that they do not accept patients with certain conditions that will be resistant? Can they drop patients who do not respond well? The evaluation system for practices has to include some flexibility so physicians can treat all patients, even those who may not respond in the ways that most impress the bean counters.
9
Every single day here in the EU I literally want to kiss the ground. This idea is so morally reugnant I can't even find words. Patients deserve care. Doctors deserve adequate compensation. That's all. We all die in the end anyway.
13
Fee for health is a good concept
1
Maybe if you want better healthcare outcomes doctors need to be better in the area of "customer relations". Doctors today treat each visit by a patient as a single transactional event with no follow up planned or enabled. I hate to say it but doctors need to use modern practices of support to make those single transactions part of an ongoing series.
Example: I changed my primary physician in the past year, my previous doctor never called nor cared to follow up as to why. I've gone into a doctor with something going on, they guess at it but after one week, one month no follow up to see if their analysis was correct. How is that good doctoring?
1
The NC “pay clinics to improve health status” is dead end road when examined on a population health basis.
This is a public health problem but the budgets for public health agencies and efforts have been underfunded for decades.
This is a socio-economic problem but addressing income and equity disparities does not get votes for politicians.
This is an unbridled capitalism problem where unhealthy foods, alcohol consumption and self indulgent behavior are pushed relentlessly. Finally, at least one company, J & J, has been found guilty of predatory marketing in this case, opioids.
6
If you want better healthcare outcomes for people in NC they should move to another state. NC has such an ingrain culture of bad health care policies that the state still has over 300,000 uninsured. More than a decade after the expansion of Medicaid under the ACA the Republican controlled NC legislature still is refusing to expand Medicaid. Improving healthcare outcomes starts with improving affordable healthcare insurance for everyone.
18
Agree with many comments. The problem is we are dealing with people, not programmable machines. Being held responsible, accepting ‘risk’ on the financial side of things will not help doctors it will only drive primarily care further into the ground. “Diseases of despair”, “food deserts”, fast food industry, internet experts with something to sell for every chronic aliment. It’s a top down problem- the doc just has an expensive mop to clean up the mess which does nothing to fix the cause.
5
NY is also doing a similar experiment. It is called DSRIP. I am not sure how North Carolina can do this successfully without Medicaid expansion. It will certainly lead to cherrypicking of patients. Those who may need more health care services particularly with mental health problems will be left out. In the short term some ACOs will get rich. Just because you spent 15 minutes extra screening patients for depression it does not mean patients with depression are managed better. They are not. They are not even psychiatrists and mental health workers in North Carolina to make this better. The state needs to expand Medicaid and spend more money on mental health if they want to be successful.
10
I’m retiring as a family physician after 30 plus years. These value based systems of providing health care are doomed to fail. They assume that an individual physician or other health care provider in a health system can have a meaningful impact on a broad array of social determinants that affect health. These are societal issues that require a difficult ground up approach that leads to better health and lowers the demand for health care services. Twenty dollars more per month to a primary care provider won’t do it. The current U.S. health care system is already bloated consuming an inordinate amount of resources. Adding more dollars to this system will do nothing. The help I need comes from a system or culture that allows and encourages good health care choices way before a patient shows up in my office.
23
45 years ago the Mountaineer Family Health Plan in Raleigh County WV put primary care docs in the driver's seat by assigning all Plan members to a primary car doc who managed their overall care. The Plan only reimbursed specialists if the visit came on a referral from the patient’s primary care physician. The same applied to non-emergency hospital admissions. A part of the primary care doc’s financial compensation was based on the expenditure experience of his or her panel of patients.
This experiment was way before its time, and depended on a federal grant for a significant portion of the income it received for taking care of a largely low income group of patients. Thus it died when the government bucks dried up. Bu the idea was working ,and these similar ideas can work today, with an outcome of more personalized patient care, better health outcomes, and cost savings as well
3
As a healthcare provider in a stunningly impoverished, rural, drug addicted area... this NC initiative won’t help doctors provide good care. We can’t make people come to the doctors, most visit once every 5-10 years for something needing immediate care, not to mention we’re treating patients who’ve been drinking solely Mt. Dew since they were 9 months old. All providers wish they could help their patients, but how can you help someone who won’t or doesn’t know how to help themselves/ who the system is against.
13
Why is everyone so negative ?
The system is corrupt because doctors are grossly overpaid and "Big Pharma" should be slapped down under the RICO laws. Those two actions would quickly fix the health care problem.
7
This will work about as well (not!) as tying teacher pay to student test scores...
13
Will any doctor want to see a chronically ill person?
15
Basing reimbursement on outcome seems to ignore one important factor, the patient in question. Basically the provider will be “punished” for the myriad factors that interfere with a patient’s ability to carry through with prescribed care. Is the system going to ensure that patients take their meds, eat a proper diet, exercise, avoid alcohol and drugs etc. I believe these factors have much more impact on a patient’s outcomes than anything providers have in their control, such as choosing appropriate meds and monitoring labs and imaging. The health care system administrators, far removed from the realities of primary care, who want to “buy health instead of health care”, seem to discount this fundamental reality. Would such a system eventually lead providers to cull the sickest and most difficult patients from their practices?
21
There isn't enough detail in this article to warrant many of the criticisms I've read in the comments. The health care industry is learning from earlier missteps with value based payment plans.
I don't necessarily agree that NC is moving faster than anyone else. Several states have ambitious programs underway. None of the programs I am familiar with are just old-time capitation. All of them have some adjustments for risk and severity. None of them preclude other delivery or coverage improvements.
We're quick to gripe about premiums, but slow to attack the underlying costs. Proceed cautiously, but proceed! You just might be able to have your cake and eat it too.
1
If doctors now act in ways that produce better better outcomes, does it really matter if it reduces costs?
3
@AACNY Yes, it really does matter. Healthcare costs are rising so quickly that no one will be able to keep up within a couple of decades unless something is done to address the problem.
2
@AACNY Outcomes should be the number one concern, but our system is such a mess that it's entirely possible to improve outcomes AND reduce costs.
2
As a breast cancer patient, I was told by my insurance company that I had a "case manager" - who couldn't help get bills paid, or find in-network providers or offer any advice at all. The whole function of the case manager was to convince me NOT to do what my doctor wanted me to do.
That is not good medicine, but it is typical health insurance tactics.
Let's look at the Mayo Clinic: it has a world-class system - health care designed by a team of professionals for each patient, individually. The entire team, from the rock star surgeons to the newest nurse, discuss the best care for the patient.
And the Mayo Clinic's outcomes are not only superior to many others, they are less costly. This is good medicine.
I know how I'd vote.
21
@D F
You can insist loudly to the insurance company vultures--I mean "case managers"-- that you don't want their intrusive interventions, or prizes, or gift cards, or second-guessing of what your doctor recommends. You are correct; their interest is in reducing the costs paid out by the insurance company, not in improving the quality of your treatment. You already have a doctor to advise you about your medications and treatment; do you need budget-cutters looking over your shoulder?
9
Ultimately patients age and start having poor health, leading to hospitalizations. How are the contractors gonna keep the quality of healthily patients up?
5
@Luis Gonzalez
Assume the target outcomes change as patients grow older.
4
Get ready for an exodus of doctors from NC.
11
There was nothing in the article about providing people in NC health insurance who don’t have it, how these programs are to be financed except the 650M pilot project mentioned, how outcomes are to be judged positive or negative, and besides some peripheral mention of new IT, how the burden will be spread out beyond the FP doctor, who already has to see 20-40 patients a day just to tread water. Addressing access to health insurance, socioeconomic and environmental contributors to poor health are issues with a 20-30 year discussion history, but nonetheless very important to finally tackle in a meaningful way. Substituting fee for service with capitation or fee for performance in the context of the present structure won’t work. The whole system need to be rethought. Of course the rest of the industrialized/civilized world already spends a lot less with much better outcomes and has universal coverage.
18
Regardless of the experiments, the Primary Care physicians should advice his/her patients to completely avoid the junk food, processed food, restaurant food, etc., and urge the patients to eat a lot of vegetables and fruits.
According to holistic practice doctors, nutrition is not a subject taught in American medical schools, many of FDA's research reports are false to help the pharma companies make billions of dollars in proits.
6
@Mbr if you think that primary care doctors aren’t advising their patients with chronic medical problems not to eat processed foods, increase intake of future, vegetables, anything that isn’t processed, you’re gravely mistaken. As a primary care physician myself, I counsel almost every single one of my patients on nutrition and exercise.
I agree that medical school education definitely needs to increase the amount of nutrition taught. But doctors are definitely counseling patients anyways.
8
And get a little exercise
@KMH, what percentage of overweight patients have you convinced to lose weight? Same for smoking. Same for poor nutrition and eating junk food. I am guessing your success rate is pretty low, probably close to zero. It is admirable that you are trying to influence patient's behavior, but in aggregate, Americans IGNORE good medical advice to take better care of themselves.
1
Massachusetts is already experimenting with the ACO "Accountable Care Organization" model for most of the Commonwealth's Medicaid patients and this is year 2 of the program. The jury is still out but the opportunity to improve outcomes for our most difficult patients may be possible thru this model. But the state's primary objective is to decrease the overall cost of care and time will tell if this is also possible. $20 dollars extra on a Medicaid patient still does not bring reimbursement close to what we get from private insurance for the same visit and the incentive to limit the number of Medicaid patients in a practice remains high. The measures of quality of care and outcomes are given less weight than decreasing TME--total medical expense-- in our system. Doctors do not control prices at hospitals, ERs and other medical facilities or the cost of drugs like insulin and asthma medications that are outrageously expensive. Even if we improve outcomes we may not be able to decrease TME. These models include financial penalties if TME is not decreased and doctors managing care optimally may still not win financially in this system, while being asked to do more work.
6
Interesting that the plan is described in these “accountable care” terms. Much of the local coverage for participants in the State Employees health plan (which is indeed BCBS of NC) has been about the “cost plus” component that is designed to deal with variable costs of procedures from hospital to hospital, clinic to clinic, place to place. I am left wondering how reimbursements for those two components—cost plus, and accountable care—are being articulated among providers. Providers, mostly hospitals, launched a major lobbying effort to get the State Employees health plan to postpone the changes.
3
This is an interesting effort, but it and the discussion about medical insurance coverage have ignored the equally important question of availability. What good is insurance, let alone discussing what and how to cover, if there is no functional access to care?
The Albuquerque Journal ran an article noting that the largest health care provider system in New Mexico did not have a single primary care doctor accepting new patients. Lest those of you on the coasts think this is just the hicks in flyover America who you take little -- if any -- note of, the article also stated that in Massachusetts, which has the highest doctor to patient ratio in the country, it still took fifty-seven days for a person to see a new primary care doctor.
I am sure there are many avenues to address this problem. Just for starters: forgive med school tuition if one agrees to work in under-served areas for a designated number of years. The same thing could be done to encourage students to go into primary care careers rather than into specialties.
Neither the media nor either political party is dealing with this critical issue: how do we encourage more people to choose a medical profession? Unless we deal with that, the inexorable law of supply and demand simply means that increasing the number of newly insured people will result in the even more difficult access to medical care for everyone else.
The Times has run many articles recently on healthcare, yet I have failed to see this issue addressed.
11
How does this not discriminate against the poor and the sick, let alone the aging?
18
Paying doctors based on the behaviors of patients (diet, exercise etc.) is just plan moronic. No matter how many times a doctor provides suggestions to a patient to lose weight, provide guidelines for eating etc. they ultimately have no control over the patient's behavior - another way for rich insurance companies to get richer by withholding payments for services provided. Doctors and their staffs have overhead etc. the fact that patients are non-compliant should not be a burden shouldered by the care providers.
33
Most physician go into Medicine to help people. They should be encouraged to follow "best practices" but this "tying their compensation to outcomes" is rubbish. Another way of not paying hardworking physicians their due.
12
This is a sham by insurance providers, an opportunity to actively limit the amount of money they pay primary care doctors. The thought that doctors should be financially responsible for their patients' choice to eat poor food, sit on their couches, and smoke cigarettes (sometimes all three simultaneously) is ludicrous. Physicians are not there to browbeat patients; they're there to offer sound medical advice.
If nothing else, this is going to encourage physicians to either consciously or subconsciously blackball the unhealthy, fast food-eating smokers out of their practice. And why shouldn't they? WHy on earth would anyone want to provide care to someone who doesn't listen to sound medical advice AND actively take money from the physician's pockets?
This is a bad plan and it would have awful consequences. Of course that's exactly what insurance companies want.
20
My primary care physician runs walking and fitness programs for her patients. Primary care gives the most bang for the buck. The only thing that might save America is forgetting the price of everything and understanding value regarding health and happiness. As long as money is number one you will be plagued with corrupt amoral and destructive leaders.
6
@Montreal Moe Moe, as a frequent commenter in this space, you should know that 'murica ain't gonna attend no walking and fitness programs. They're gonna eat whatever they want, smoke and drink as they please, shoot guns, and drive pick-ups. No doctor or socialist gubment agency is gonna tell them how to live their lives. Gubment just needs to pay for their health care and get out of their lives.
As a practicing physician who has worked as a provider/manager in a capitated system, I can tell you that this solution is not perfect. You can provide wrap-around treatments and some people will still get very sick and require expensive care. At times the cost of care will threaten to exceed the capitation budget, just by the law of averages. Especially at the end of the fiscal year providers must be prepared to resist simply denying care in order to eke out the available funds.
But the main problem is that a capitated system will in the end do what it can to exclude very ill multi-problem patients. The system *must* be set up to prevent health care delivery organizations from choosing only healthy patients as members. (Look at the proliferation of concierge practices for a clear example.) And when such an organization is operating in a low income, low social support region, it must be recognized that the cost of care per patient will inevitably be higher than in an area where people have more resources. Social advantages like the ability to take time off work without getting fired, easy transportation to get to appointments, child care, and access to healthy food are not evenly distributed.
Certainly it is better to have a system that allows providers to design and adjust care delivery depending on the unique problems of their community, rather than being reimbursed simply for visits and procedures. But there are no easy answers.
20
Doctors can promote established screening programmes and be reimbursed according to uptake. This is one of the easier methods of identifying diseases earlier and improving outcomes.
In Scotland ,general practitioners must get a defined uptake for cervical screening to maximise payment for that programme. All screening needs adequate uptake to be cost effective. This is an area for incentives.
Wellbeing no longer means free from disease or illness. It requires an effort to improve all aspects of life. Housing ,employment and education and then health. Promote immunisation and screening programmes to get maximum return for your dollar.
3
Like many good ideas, the devil is in the details.
Many cases of diabetes and high cholesterol the lab test numbers can be treated with medication even if patients don't make many lifestyle changes.
The problem is when you get into a disease like drug addiction where medications may help but also mean the patients have to completely change their lives for treatment to be successful.
I fear this will become an excuse to pay physicians more for doing relatively easy things and not for doing the hard things. In fact, probably doing the hard things wouldn't be worth the time it would take just to get a small additional amount of money.
7
@Steve Exactly. Doctors will hire "counselors" to do "education." They'll be "reimbursed" for these "preventive services" and based on these "metrics" will receive additional "rewards." It will take 20 years to measure the "outcomes." In the mean time, the clinics make money and gubment believes they're doing something good.
2
Such a good idea. People take the days off to see their physicians and so they better get things done the right way.
Seems like this might transform medicine into something like how "ambulance-chasing" lawyers operate -- they only get paid if they win, so they only take cases that have the best chance of winning.
8
This scheme has so many ways to go south it’s not even funny.
Why try some harebrained scheme that will backfire as patients are dumped into the streets because they didn’t recover, when the Mayo Clinic has been successfully paying physicians a salary for generations?
Oh, but of course, this isn’t about innovation or providing care at all. It’s just a barely disguised excuse to cut the budget, and dismiss the consequences which will fall squarely on the people least able to afford it.
But, who needs poor people, right?
Well done N.C., well done!
14
Honestly, the thing is to have better relationships--or actual relationships--between people. A doctor that looks at you, asks questions, takes more time, isn't forced to itemize questions for billing purposes. When the focus is on profits, there's not a system in the world that will support relationships, and support care.
5
It seems to me at first thought that a system like this would cause medical students to go into plastic surgery or obstetrics rather than oncology or internal medicine. Some branches of medicine come with a higher success rate than others.
6
I'm certainly no expert, but it seems basically a backwards approach. Some of the ideas are good, but the real objective should be to make health care accessible to everyone. Big industrial giants like Japan and Germany have national plans that are superb compared to America, along with a lot of other programs. Why not copy them?
6
@Paul Shindler North Carolina is absolutely rotten with Koch Brothers money. Any solution they choose will benefit the insurance companies first, and citizens second.
4
@Just some guy
Thanks - my instinct was correct. It sounds like "trickle down economics" - which is a scam too.
3
Law of unintended consequences- firing patients who are not "healthy" It's a thing already. It will only get worse.
17
This plan encourages general practitioners to sometimes treat beyond their expertise. Referrals to specialists get withheld ostensibly to save money. Extensive testing for elusive diagnoses are postponed. Non compliant patients or even patients whose diabetes , hypertension, or cholesterol is difficult to treat will be dropped or turfed. This plan is reminiscent of the old HMO centers where the primary physicians got a print out of every cost they incurred and hesitated to ever send a patient for more specialized care or tests
13
As a physician who’s struggled under these “outcome based reimbursement” for years, I can say it’s a dreadful idea for patients. Clearly driven by a profit motive.
Of course the insurance companies want patients to have better outcomes. This is not altruism. It saves them money.
So do I, even more than they do. I have spent my 35 professional years trying to help people get better, not because it makes me money (it doesn’t) but because that’s why I became a doctor. To help people.
I wish I could get all my overweight patients to lose weight, and diabetics to eat healthy, and smokers to quit. I can try to facilitate this, but it’s ultimately not in my control.
This scheme is why I left private practice. Lots of other physicians will leave too, or “cherry pick” their population so they’re seeing only healthy patients.
North Carolina is being scammed.
62
A very interesting development. Another approach to making sure that private insurer's still make money.
It is oddly big brotherish for a state that refused Medicaid expansion. In general the idea of really focusing on health outcomes, accounting for broader issues is a good idea. Poverty, food availability and aspects of culture have a profound influence on health. What people eat and how they take care of themselves is truly significant for health and is tied up with big Grocery Ag, Chemical Ag, manufacturing and farming, PhRMA, Fox News and hate speech, religious grifters, political grifters, understanding about history, "moral" influences by indoctrination rather than real thought and consideration, etc.
How many of those things are going to be addressed? Not many. This is a good idea that is being engineered and co-opted to making the financial elite more financially elite.
A better approach is also more straightforward. Medicare for All, better education, better financial security and money out of politics. Those will improve health outcomes and bring down costs far more reliably and quickly than still more Rube Goldberg insurance contraptions to keep funneling health care money to the financial elite.
12
The big catch here is that North Carolina hasn’t expanded Medicaid, and has dismantled our once-good community mental health system. We know that mental health conditions— especially untreated ones— lead to worse health outcomes. The state moved to managed care for its behavioral health system in 2012. Many people simply can’t access care, and in some counties, involuntary commitment rates have nearly doubled. In the BH system, MCO executives rewarded themselves with high salaries. The state has awarded multi billion contracts to for profit insurers on this next round of progress. I am deeply concerned for people with complex needs. There will be no incentive to serve them if it’s unlikely to get the good outcomes. We can already see the tiered systems of care— great care if you are wealthy, and perhaps nothing at all if you are poor.
22
Nowhere in this article is there any mention of other forms of healing - acupuncture, chiropractic, homeopathy. It's disheartening especially for someone like myself who has benefited greatly from these modalities. Because my insurance only covers allopathic providers, I pay out of pocket for acupuncture. I'm lucky in that there is a community acupuncture clinic where one pays on a sliding scale basis but patients should be at least informed of appropriate alternatives by their medical providers.
3
This is insidious. The state and insurers will pressure providers to the point that they won't want to provide care to patients with conditions that are difficult to diagnose or treat, or whose conditions are at an advanced stage. It also will be against the interests of providers to provide palliative care. The insurers and the state will end up paying little or nothing for difficult cases. An outcome of this sort absolutely is intended. It's no accident that we see this "experiment" in North Carolina.
35
@Stephen Merritt Amen.
3
I wonder how they are going to handle large vs small medical centers? I wonder how major centers that handle sicker patients be handled in the mix?
How will large versus small group practices will be compared and allow for geographical variations? How will specialty groups of varied sorts fare? What about expensive meds that are needed by certain subgroups in certain specialties (and the decisions that go into using them)?
I do know that if the decision is left to politicians they will very likely make a colossal mess. I am suspicious of what will happen as this rolls out. Maybe all the good intentions can be put into practice. None of this means that health care delivery should not be continuously improved.
5
Isn't this approach similar to the "outcomes-based" reimbursements that Medicare has been trying, or is moving to?
1
@hdtvpete Yes, but BCBS-NC has a better tool set (i.e., wider scope) than Medicare's BPCI.
I guess NC is no place to become terminally ill, since MD's will get penalilzed for failing to save you. If they really want to cut costs, go after insurance CEO's and boards of directors. A ten percent cut in their reimbursement could probably fund everyone's health care in NC. And they would still be mega millionaires.
31
@Mike While I'm not disagreeing that executives could stand to make less money, you're comparing a fraction of millions against billions and billions of dollars in medical expense. In 2014, NC health care costs were at about $72 billion. How would skimming 10% off of millionaires cover that expense, exactly?
2
So the provider will be penalized for whatever the state says is not a healthy outcome. What is the patient's responsibility toward that healthy outcome? Patients often don't take medicines as prescribed or don't take them at all. They don't make prescribed lifestyle changes. This article does not address the noncompliant patient.
23
Another way to blame someone else for my mistakes. What if I don't take the doctor's advice?
What if I don't have a healthy lifestyle, nutritious diet and a good fitness program- all essential for well being, though not the whole of it. Despite doing all that I will get sick or injured, I will get old and I will die. A doctor is not a magician or miracke worker. I am responsible for my health firstly and last; others are there to help, advise, aid and not to take over. So why are you telling a doctor to take over all the responsibility? They are not my constant minders, I am.
38
It all sounds wonderful-- and certainly preventive care is necessary BUT -- we all age.... My wonderful primary care physician was perturbed when my weight was good, I was in my 50s but my metabolic score was high -- Diabetes 2- yup. My MD brother announced that his wife now in her 60s had high blood pressure -- yup. Age happens to us all... and we might be able to do a little bit about it with life style changes but rarely as much as we might like or hope. (There are miracles!) PS my stepmother with hypertension from age 39 is soon to be 91... and while ambulatory issues no dementia... pretty self-sufficient.
I would like to see all morbidly obese people I see on the street sent off to biggest loser camp, but that does not seem about to happen. If it does happen in NC, I truly applaud the effort. Obesity like opioid use is the result of a complicated addiction so far as I know.
10
Once again, this is really a bad idea. Doctors have only a role in the health of a nation and "incentives" is just playing capitalism with our health.
23
There will always be a debate as to whether this payment method focused health providers on quality over quantity, or whether it provides incentive to withhold care. Most likely some of both - but much care is unnecessary and at times counter-productive.
Furthermore, providers would have incentive to combine case management/quality efforts with integrated behavioral health services. Attention to individual health care behavior (e.g., weight control, medication adherence, lifestyle changes) can also result in great cost savings.
These issues have been largely left out of the current political debate (whether or not to do Medicare for all). How we deliver and finance care is just as important as whether or not insurance companies are involved in the process. Here too, there is always a debate as to whether private-sector economic motivations are better or worse than the often mismanaged government systems.
North Carolina is at least trying to do something meaningful. We should all be of the mind to look at actual results of this approach, rather than fall back on our long-held beliefs that have little basis in evidence.
12
Don't complicate this. While any program is better than the current (pre ACA) republican plan of be rich, don't get sick and or don't have a bad life event while billionaire big pharmaceutical and HMO execs make billions off of the misery of sick people, any one of our peer countries plans is better than ours.
We have the most expensive system with at any one time up to 50 million Americans under or not insured while our quality of life stats keep dropping re our peer countries.
32
Health care produces very little in the way of health. Meeting basic social, economic and biological needs produces health. Educational level is actually the best predictor of health status, not whether you see a doctor regularly. Giving more health care to poor populations means a lot more health care and very little more health. If NC really wants a healthy population, it needs to address basic social and economic inequities. Start with building more schools.
26
I believe this was called "capitation" the first time around. Docs were accused of withholding care by many patients because the cap payments weren't high enough supposedly. Who knows? It pretty much didn't work well. Now, docs are incented by their practices to do as much as possible whether you need it or not - more visits, more procedures etc. = more money. I don't think we could have a more dysfunctional healthcare system if we tried.
27
I'm all for ending total reliance on fee-for-service, but it's important to consider unintended consequences when planning big changes. One thing that can go wrong in this case is that if NC financially punishes doctors whose chronically ill patients aren't getting better, many such doctors would logically refuse to continue treating their chronically ill patients and taking on new ones, and that would not be a good thing for public health. They won't get their prescription meds. They may die sooner.
The doctor can refer a patient to a dietician and wellness manager but can't force the diabetic heart patient to go or to stop smoking, guzzling beer, and otherwise eating an extraordinarily unhealthy diet. Doctor reimbursement should not depend on poor choices by patients.
66
@Clutch Cargo
I agree, patient compliance plays a large part in how well they do, in addition to what the doctors prescribe/suggest.
6
One of the sickest things I’ve ever witnessed is NC turning down Medicaid expansion under the ACA.
The former GOP guv until 2016 , Pat “I’m not a scientist” McCrory and the Tea Party controlled legislature refused to accept over 3 billion in free federal money under the ACA since it’s passage, which would have covered over 400k poor folks in the state, mainly children.
Even a new Democratic governor cant get Medicaid expansion past the Tea Party legislature.
Pure partisan politics was and is the basis, literally costing people their health and lives.
Like I said, sick.
96
One does not “buy” good health or good health care. One provides good health care and good health. Equating health with cost is a fundamental philosophic mistake. Insurance companies and business are extremely adept at hiding their true motives from those stupid enough to believe them, which is profit margin. Health care for profit is basically, fundamentally flawed whether it is an insurance company, a hospital, or a pharmaceutical company. This country bought into this proposition years ago. It is a losing one except for those selling it.
101
@Allan Bahoric, MD - Your argument would make sense if the country had unlimited resources. It does not - not even for something as basic as health care. Any system with limited resources by definition, has economic value and therefore can be equated to costs.
It's OK to stay that we should spend unlimited resources on a very basic level of health care (say saving people's lives in an accident or providing sustaining life for the indigent) and then assigning an economic value on all health options above that (say, advanced diagnostics or drug costs).
Society has to make choices on some basis. Cost is one such choice. Saying otherwise is just ignoring reality.
2
@deedubs:
The good doctor isn't arguing for unlimited resources. He is arguing the FOR-PROFIT health systems are the problem.
If we had truly NON-PROFIT health system, we would still need rationing of care, like the NHS UK. Here is the US, private corporations do it for those covered; those with no coverage, just get sicker, disabled, and die. That's also de facto rationing care. In the UK, it's based on efficacy, costs negotiated with the pharmaceutical companies, etc. based on the quality-adjusted life-year (QALY), among other factors, not "we need to meet our shareholders' value commitment."
Right now, we have more economic rationing than ethical rationing, which is cutting down on futile care. We over medicalize old age, like giving 100-year old cognitively-impaired people pace makers while we have 20-year olds dying from rationing expensive insulin shots.
OECD in 2018 calculated that the UK spends on average per head on healthcare $4,192, with a life expectancy of 81.6 years. While the US spends more than twice this amount, $9,892 – far more than any other country in the world – and yet life expectancy is far lower.
4
Paying doctors based on health outcomes will cause people without the means to buy healthy foods left to suffer without health care. Why would doctors see poor, unhealthy patients if there was no money in it?
40
Tying doctor compensation to health outcomes will incentivize doctors in primary care to favor patients from wealthy backgrounds who have better health outcomes long term for a variety of reasons.
76
If the government of North Carolina supports this, there has to be a catch. There is no way that a state with NC's woeful track record could possibly be trying to benefit its citizens. Cutting medical benefits, yes. Health care for its citizens, no.
43
@Barbara8101
North Carolina presently has a Democratic governor, Roy Cooper, who wants to improve the track record. He is counterpoised by a Republican-dominated legislature - that is the catch.
11
@Barbara8101 While I can appreciate your suspicion of anything associated with North Carolina's government, the NC Dept. of Health and Human Services is led by Dr. Mandy Cohen, who was appointed by North Carolina's Democratic Gov. Roy Cooper.
6
Payment to doctors by insurers based upon the number of lives cared, with bonuses for good outcomes, is not a new concept. It was a prevalent method of reimbursement for medical services by primary care physicians in the 1990s, but proved not to be particularly popular among doctors and certainly not profitable to insurers.
As a primary care physician, this model is attractive, however. Our mission is as much to prevent disease as it is to cure it. While there has been little recognition of the effort primary care providers need expend to educate and encourage good health habits, rewarding that effort provides gratification. Fingers crossed this model lasts.
18
good idea to increase funding for primary care. bad idea to link doctors' pay to long term patient health outcomes. those outcomes are overwhelmingly driven by factors doctors don’t control, by the patients’ health when they show up, and by their willingness and ability to live a wellness lifestyle. people know they should eat lean, stay active, no tobacco or recreational drugs, minimal alcohol, buckle seatbelts, lock up guns. if they aren’t living that way already, doctor’s advice is far from certain to induce behavioral change. it’s not technically difficult to grind through lists of validated screenings and behavioral and pharmaceutical interventions. it’s virtually certain that if doctors are paid in proportion to measured wellness of their patients over time, doctors will quickly break into two groups- highly paid wellness gurus who manage to direct unhealthy patients out of their practices, “sorry, can’t help you”, versus drudges caring for the sick ones, drudges punished financially for not driving away chronically ill patients regardless if they persist in bad choices. i was a clinic doctor for 19 years of mostly happy drudging. after absorbing all the financial punishment i was willing to take, i care for patients as a hospitalist. expect to continue to drive people willing to care for the chronically ill out of practice if you punish them for failing to make chronic patients better, as opposed to caring as best they will allow whether they get better or not.
81
@manfred64
About 10% of the patients incur 90% of the health care costs. (It's a Pareto distribution.)
So an insurance company or medical practice that gets the 90% of low-cost patients will make money.
The ones that get the 10% of high-cost patients will lose money.
Therefore, the financial incentive is to avoid the high-cost 10%.
4