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Making the Wrong Diagnosis, Getting Paid Anyway
Accurate
diagnosis is critical to getting the right treatment. Under current
payment systems, physicians often have a financial
incentive to order more diagnostic tests by other
providers rather than spend more time with a patient
to explore symptoms more carefully. Moreover,
under current fee-for-service systems, physicians
are not financially penalized for ordering more tests,
regardless of whether they are necessary to make an accurate diagnosis/prognosis,
and providers that supply testing information used in making diagnoses/prognoses
are paid regardless of the accuracy of their collection and interpretation
of data.
Pitting Hospitals Against Physicians
Hospitals
and physicians are currently paid under completely
different payment systems for caring for a patient
in the hospital. A hospital seeking to improve
quality or reduce costs of inpatient acute care may
not be able to do so without the cooperation
of physicians (who may be financially penalized for doing so under a separate
fee-for-service payment system). Physicians
who seek to improve quality of inpatient acute care
may not be able to do so without the cooperation
of the hospital (which may be financially penalized under a per diem or
DRG-type system for doing so).
Rewarding Adverse Events
Under most payment systems,
providers are paid whether or not patients experience adverse
events under their care (e.g., infections). In fact,
providers are generally paid more for
patients experiencing adverse events, particularly
serious adverse events resulting in multiple complications. Although some studies have reported
that the increased payments to hospitals for adverse events are not sufficient
to cover the increased costs of care, PRHI research suggests that reducing
adverse events may hurt hospital margins. Moreover, physicians paid
under fee-for-service arrangements likely receive additional fees for additional
care of patients who experience adverse events.
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Pushing Expensive Treatment at the Expense of the
Patient
Providing palliative care, rather than treatment, to patients
in the final stages of terminal illnesses can
reduce costs and improve patient comfort, but
current payment systems often reward expensive treatment
measures in the final stages of life.
Possible Solutions
There are different ways to pay for
health care that could reduce or eliminate the penalties and disincentives
built into payment systems. But few
significantly different systems have been attempted
or evaluated.
Payment demonstration projects can make
progress on payment reform. A wide variety of payment
demonstrations would be needed to address the variety of the nation's patients,
conditions, and geographic needs. Experimentation and evaluation,
hallmarks of evidence-based medicine, will also likely
be needed in order to develop the most effective cure for the ills of the
payment system.
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