To continue the previous posting on health care; there are two other important factors that have decidedly altered the relationship between physicians and patients in the last five decades. The changes have been gradual, not abrupt, but noticeable.
The first change has been the segmentation of care notably the increased presence of the hospital as an institution in delivering all aspects including the physician. Hospitals a big up to employee physicians called hospitalists which assume care of the patient wants the patient enters its door. The primary care physician or family physician or referring physician is in many cases no longer allowed stead hospital privileges this is most marked when related to primary care generalist or internist without specific sub specialty.
This process began initially with the allocation of a concession to the emergency room groups. Their practice was limited to the emergency room. They had specific duty hours. Once the physician was off-duty he had no contact or responsibility to any patient seen by him in the ER. This was contrary to the old fashion idea that a physician was legally responsible 24/7.
The next group that appeared as hospital physicians were usually Critical Care specialist; who is most often pulmonary specialists trained in the administration of oxygen and maintaining of respiration. Much of this knowledge was foreign to most of the physicians who had outside practices but admitted patients to the hospital. This particular specialist was followed by other specific specialists to a point where the hospitals begin to employee full-time salaried doctors in all fields. They work shifts the covered all the different wards in the hospital. They excluded the primary care physician. Physician loved positions like this because their responsibilities ended when they were off-duty. They could now spend more time with their family; they were working a work week similar to those in business.
The other revolution which occurred started with the HMOs where the insurance companies attempted to instead of fee-for-service compensate physicians for treating their patients under a capitation program. Capitation meant that the physician was paid for the number of patients registered in his panel. The more patients he had the more money he could earn; therefore it would induce the doctor to spend less time per patient in order to increase numbers and his income. Panelists were also rated on their efficiency according to the insurance company, which in essence spent how they kept the patient from high-cost hospitalizations, referrals and tests irrespective the patient’s needs
Fortunately although capitation with its set panels met patient resistance usually because the patient was obligate to go to a specialist in the network. Specialist out of the network although perhaps superior most often would not be compensated by the plan.
I have copied an explanation of the newer ideas on paying health care providers.
In the late 1990s, physicians and consumers decisively rejected capitation on the grounds that it motivated doctors to skimp on care and made it difficult for patients to gain access to specialists. Today, capitation survives mainly in California and a few other managed-care hotspots.
The new payment models, like capitation, involve budgeting. But they combine that with quality measures to ensure that doctors aren't cutting corners on care. All of these systems pay doctors fee for service, although those fees and/or bonuses may go up or down with performance. The overall goal is to induce physicians to provide high-quality, cost-efficient care.
In 2009, Medicare began paying bonuses to physicians and other clinicians who qualified as "successful" e-prescribers — that is, they reported electronically transmitting a certain number of prescriptions from their computer to a pharmacy computer. In 2011 and 2012, the bonus equals 1% of a clinician’s fee-for-service (FFS) charges. It drops to 0.5% in 2013, the last year of the incentive program.
Meanwhile, physicians who have not satisfied the complicated rules for e-prescribing this year face a 1% reduction in their FFS charges in 2012. The penalty increases to 1.5% in 2013 and 2% in 2014.
Here's a brief summary of these payment models, all of which are either being piloted or will soon be tested by Medicare and/or private health plans.
Bundled Payment: Unlike case rates, which apply only to individual procedures, bundled payments cover care provided across care settings and over specific time periods.
In Medicare's Bundled Payment Initiative, which is already underway, the Centers for Medicare and Medicaid Services (CMS) will bundle payments for a hospitalization, for post discharge care for 30 days, or for the inpatient stay plus post discharge care for 30 or 90 days, depending on which option a provider or group of providers chooses.
Physicians who participate in these arrangements will be paid fee for service and will share in the savings if total costs are less than the budget. Their payment will be reduced, however, if costs exceed the budget. Under a fourth option, CMS will prepay the hospital for an episode of hospitalization, and the facility will divide the prepaid amount with physicians and other providers.
Episodic Payment: In addition to bundled payment, other forms of episodic payment are being considered. For example, several large healthcare systems are piloting Prometheus Payment, which rewards physicians for practicing efficiently and avoiding complications.
Physicians are paid fee for service for performing a portion of an evidence-based guideline, and their payments are debited against a care team's budget for an episode of care. (The episodes may be built either around procedures or around chronic disease care for an extended time period.) If the care team avoids complications, the physicians share in the savings from averted emergency department visits and hospitalizations. They can also get bonuses for meeting quality goals.
Accountable Care Organizations: Accountable Care Organizations (ACOs) are groups of doctors and hospitals that agree to coordinate patient care across care settings and to deliver seamless, high-quality care. If they meet certain criteria, ACOs will be eligible to participate in a Medicare shared-savings program, starting in 2012.
CMS offers ACOs 2 options for reimbursement, both contingents on the providers meeting CMS' quality benchmarks: 1) share any savings they produce with Medicare for the first 2 years, and share in both surpluses and losses in the third year, or 2) take upside and downside financial risk for all 3 years. Physicians will be paid fee for service at the current Medicare rates; but, under option 2, their payments will be adjusted downward if the ACO goes over budget.
Global Prepayment: Some health insurers are testing new approaches to "global capitation," in which all care provided to patients -- including professional and hospital services -- is prepaid. For example, Blue Cross Blue Shield of Massachusetts offers an "alternative quality contract" that combines global capitation with quality bonuses.
A dozen large healthcare organizations have accepted this contract so far. The Blues plan pays physicians fee for service, and those payments, along with hospital and other costs, are reconciled against the budget at the end of the year. In groups with salaried physicians, however, the fee-for-service payments are only an accounting device. For example, at Atrius Healthcare, which includes six physician groups in eastern Massachusetts, physicians continue to receive salaries and production bonuses that are not affected by the alternative quality contract budget.
