July 24, 2024: It’s the Delivery System, Stupid!
Moving from Fee for Service to Prospective Payment in Primary Care: Advanced Primary Care: The Future of Primary Care – Part 15
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“It’s the delivery system, stupid!”
James Carvel, an advisor to President Clinton during his run for the White House, famously wrote on the wall of their office. “It is the economy, stupid! It was his way of staying on message.
We’ll follow in his footsteps with our saying that is intended to keep people’s attention focused on the real issue underlying healthcare reform. It’s the delivery system. stupid!
Many people believe that doctors are greedy money-oriented bastards. If you change the financial incentives, they’ll change their behavior is the thought. There is a whole pay-for-performance industry dedicated to this.
What people don’t realize is that this is not the case for most doctors. And doctors work within a system of care delivery that, as an individual, they have very little control over. They are trapped, especially in primary care, by a hamster wheel that keeps them struggling to get through the day.
It is far easier to change the payment system than it is to change the delivery system. A payer can negotiate for a new payment system with the healthcare providers and with the signing of a pen the new financial payment system is in effect. While it’s true that this involves a lot of work, it’s still pales in comparison to changing the delivery system.
Think about it. All of the practitioners and administrators in the current healthcare system grew up in the fee-for-service hamster wheel world. They adapted to it over decades, it’s all they’ve ever known for the most part. The medical students and residents in our current workforce training system are all learning how to practice in that model. Only those who spent time in the Veterans Affairs system have experienced something different.
So along comes a new model, which we call prepaid advanced primary care and the docs and administrators at all level don’t know how to behave. The systems they’ve created that direct and constrain their practice behaviors, the teams they’ve created to support their current delivery of medical care, and the entire administrative system has all been formed in the fee-for-service, reactive care delivery world
Changing the delivery system requires near radical learning at all levels. It’s not just the Docs, it’s not just the team that supports them. It’s all of the administrative infrastructure that surrounds them as well.
We say this with no disrespect intended. In the fee-for-service model, administering a primary care service line is a relatively straightforward enterprise. We realize that the people in these administrative positions work hard day in and day out to manage things
All the metrics and the management tools are relatively straightforward. The more you do, the more you make. Get them in – get them out; get the docs motivated to do whatever it takes to generate revenue.
This is far different from prepaid advanced primary care, the payment model we are presenting in this new model, It’s all about keeping people healthy. It’s about them not using services that are unnecessary
Within the delivery system, it is only the docs who can discern what is necessary care? The administrators are totally out of their league when it comes to this.
This transformation is going to require learning at all levels and learning makes many people uncomfortable. They want the rules and the clear protocols and those are not easily laid out.
It’s the delivery system stupid! And it’s going to take physician leadership within the practices and within the systems to make this work
Currently only about 5 to 10% of all contracts involve risk and even less involves full risk. It is very hard to change the current delivery system when the revenue that the systems require are split between prospective payment and fee-for-service payment. Until the prospective payment gets to 50% or so of the business on which the providers/systems rely, it is very inefficient to run two types of payment systems
So the change is slow and for many they cannot see evidence of transformation. They become disillusioned with the promise of value based/prospective payment.
It takes the innovators and early adopters among both the physicians and the administrators to see the change and to seize the moment
Carpe diem primary care. Your time is at hand. The revolution has begun.
Scott Conard, MD Michael Tuggy, MD Susan Lindstrom Laurence Bauer, MSW, MEd
scott@scottconard.com MTuggy@converginghealth.com slindstrom@mypha.com Laurence.bauer@gmail.com