Two articles appeared in the New England Journal of Medicine on October 1, 2009. The first, by Dr. Francis Crosson makes the case for integrated delivery systems. It favors the salaried physician structure I referenced in prior posts, with prospective or capitated payments, recognizing that the ability to achieve this transition will be influenced by “local market realities.” In the case of Medicare, he proposes a system whereby financial risk is shared by the government and the care providers (‘delivery systems”). 

The second article, by Dr. Denis Cortese and Jeffrey Korsmo, talks about a high-value health care score (value = quality ÷ cost) to define institutions most deserving of patients and patient dollars, to get health care on the “right track.” They contend legislators “must establish new ways of providing fair payment to doctors and hospitals offering high-quality, lower-cost care,” through value-based payments incorporating patient outcomes and safety, among other things. They recognize that critics argue currently available metrics are problematic, as they may not adequately adjust for variables such as “severity of illness, poverty level or minority status of patients.” They agree that available data are imperfect, but defend their contention with the statement that “paying for value would be a significant step toward evidence-based purchasing” in the “vacuum” in which Americans currently make health care choices. 

I have no beef with integrated systems and have cited the need for a more robust electronic medical record in this regard. A salaried physician structure may be the road we need to travel, and one can hardly argue with a value-based medical system. Still, the devil remains in the details: What is a physician’s time and expertise worth? Who will be deciding on the prospective payments and the relative risk of the payer and the provider? Whose metrics will we be using in deciding value—will the providers have a role in defining this or will it be shoved down our throats like they are trying to do with the current health care legislation (“before Congress recesses”)? 

The gap between altruism or “the right thing” and pragmatism or “the real thing” can sometimes be more dizzying than the Grand Canyon.


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