Incentivizing Quality in Healthcare Should be the Norm

November 16, 2011

The patient got better. That should be the standard of how physicians get paid, and of how American medicine is conducted.

I recently had a patient with severe Crohn’s Disease on my service in the hospital. He had complications of Crohn’s which led to multiple readmissions for the same problem. Prior to coming onto my service, a consultant recommended giving Humira, a medication used for advanced severe Crohns refractory to other treatments. However, the patient had never before received Imuran, a drug considered the standard of care for Crohn’s. The consultant’s recommendations were followed, but the insurance company refused to pay for the expensive Humira since Imuran had never been tried. My hospital had to swallow the payment.

This is one example of how un-necessary and poorly coordinated care leads to poor outcomes and excess medical expenditures. When this patient was brought onto my service, I realized that thousands of dollars had been spent, the chief complaint hadn’t been addressed, and the standard of care hadn’t been practiced. I realized that I had a limited amount of time to maximize quality. I also wanted to show the insurance company that we can do things better. So I did the requisite testing to see if the patient can safely tolerate Imuran, managed his symptoms with inexpensive medication, addressed nutritional issues aggressively, talked to his family, and within three days, he was smiling and out of the door, off of un-necessary medication, and taking only essential medication, which happened to not only be standard of care, but also inexpensive.

My management not only improved the outcome, but also led to the patient to be immensely satisfied. Furthermore my care was less costly than the care given by the previous clinicians. What did I do differently? Well I know the standard of care for illnesses in patients I treat; I spent a lot of time communicating with the patient, and I focused on inexpensive harmless methods of healing such as the use of opiates for pain control, a plant-based diet, the use of probiotics, and the use of rapport to connect with the patient. Frankly, I deserved to be paid more than the fancy consultants, sub-specialists, and others who gave their opinion, billed Medicare (fee-for-service) daily, and who did nothing to either improve the patient’s outcome or promote evidence-based medicine.

Will I be paid more? Probably not, since the reimbursement coming to me is nothing compared to that going to surgical and subspecialist consultants. While these highly-paid clinicians spend their Saturday afternoons on the golf course, I’m providing cost-effective, clinically-sound care, and getting paid less. (Of course my malpractice liability premiums are less, but that’s a separate issue!)

I gave a call to the insurance company to let them know that I can help them save money and improve outcomes in this patient. Why make such a brash move? Because I witnessed the fact that my clinical decisions led to healing in this patient - that’s why. The patient got better. That should be the standard of how physicians get paid, and of how American medicine is conducted. Physicians should be ranked based on how healthy their patients are, and how effectively patients heal from reversible illness.

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