Searching For The Imperfect Solution

This past weekend in the state capitol, my professional organization asked me to participate in an interesting meeting talking about health care payment reform and how to improve the health care delivery system. This was sponsored by the state of Ohio and their Health Care Coverage and Quality Council. It was the first meeting that I've been to where there were physicians, hospitals, insurance companies, and patients - all trying to put our heads together - present our points of view - and try to come to consensus. Did we come to consensus on solutions, not really - only that we will continue the conversation. There is no perfect solution that will make everyone happy, but we will strive to try to get to that best imperfect solution.

When is comes to health care delivery and health care payment, there was a lot of discussion on physicians and hospitals - meaning health care providers. The motivating factor in these cases uses terms like payment, lack of payment, incentives, bonuses, and penalties. I also learned some of the current buzz words including accountable care, accountable payment, global payment, comprehensive care payment, and others. I agree that the health care delivery model that is probably the one to look to is the Patient Centered Medical Home. And, the complicated entity to handle the payment question is the Accountable Care Organization. (Other states are also looking at solutions like this. You'll see in today's news that the Massachusetts Medical Society voted to endorse the "global payment plan." Addendum: Following the previous news report, the MMS issued this statement clarifying its position.)

One of the recurring questions that came up during the day was this: What will motivate patients/consumers to take a greater role in their own health? Motivating factors for patients who are required to pay deductibes and co-pays will be different than the motivating factors for patients who are not required to pay deductibles and co-pays. What about those who are unwilling or unable (ie - significant mental illness) to be an active participant to improve her/his health? Providers will be forced to suffer penalties for not reaching quality benchmarks. What if patients do not reach some pre-determined benchmarks for their own health? Will there be consequences for patients (other than the obvious health ones)? Should patient accountability be an expectation here?

As a final observation, there was a huge missing piece that was not discussed at all. The topic of liability reform, malpractice reform, tort reform - whatever you want to call it - never entered into the discussion of health care delivery and health care payment reform. If I, as a primary care physician, am going to be asked to brainstorm about innovative ways to deliver health care, all I'm asking is to somehow be met halfway and ask for relief on liability issues.

If I'm going to be asked to be a better financial steward with the health care dollar, why not try to remove those evil phrases of "defensive medicine" and "excessive testing" from my mind. Why do some symptoms that present to the ER given the "million dollar workup?" Is it good medicine, maybe. Is it fear of missing something and a lawsuit down the road, more likely. A lot of the discussion was on a comprehensive plan including providers, payors, and patients at the table. In my opinion, without significant tort reform, the question of lowering health care costs in the United States will remain unanswered.