If you don’t follow health care too closely you might not be aware that over the last ten years or so there has been a huge effort to implement what is loosely referred to as “value-based purchasing”, which generally means paying health care providers for the outcomes they achieve, not just for doing something. Medicare, Medicaid and commercial payers have all jumped on the bandwagon. One thing this does for sure is raise administrative costs for providers, but does it improve patient health or lower spending. At a macro level it sure doesn’t look like it. A recent study published in Health Affairs attempted to survey the research on whether value-based purchasing was achieving its goals. (HA Study)
In general, the past research has shown some possible reductions in spending, but no change in quality outcomes. These authors focussed on whether certain design features might account for more impact. More intensive programs obviously cost more to administer for both payers and providers, and those costs should be considered in determining any spending reductions. The authors reveiwed 24 programs, nine of which they characterized as high-intensity. Their analysis suggested that value-based purchasing programs generally had a positive effect on spending and quality, but the effects are small, and quality is not generally measured by actual health status of the patient. Higher intensity programs were generally more effective. The study isn’t particularly useful in my view, because it is basically non-quantitative and does no review of administrative costs or of actual patient health changes.
This doesn’t surprise me. The trouble with healthcare outcomes is always that patients are free to choose whether or not to follow good medical advice. Those who show up in hospital settings more frequently tend to be those who are LEAST likely to do what I recommend.
Making people responsible for payment of their own medical bills is the best way to get people to do better, but there will always be a low insight segment of the population who never sees the connection between their choices and their outcomes, or who lack the will to do anything differently.
My main concern with this approach of measuring outcomes is that there is an increasing tendency to blame people for getting sick. (Mid levels seem to be more prone to this.) Of course bad things just happen sometimes regardless of how careful someone is. The blaming of patients for their illness is driving another wedge between doctors and patients and this further makes patients less likely to follow good advice.
My practice frequently hears from people who are angry with other practitioners because the patient can’t or won’t do what the guidelines say. Many are enamored with “natural remedies “ which clearly don’t work or they wouldn’t be coming to my office. There are always some people who can’t be helped but they mess up the good ratings when outcomes are being measured. Good thing I don’t bill third parties…