As we all know, healthcare is a hot button topic that spans the range of political ideology to involving ones own particular morals and ethics. The current President Elect and Congressional Republicans are currently scaring the hell out of millions and millions of Obamacare patients regarding if they will repeal the current insurance benefits and disability payment system while Democrats are trying to quit crying long enough to figure out what happened this presidential election cycle instead of standing up for current reform efforts already implemented. Insurance companies are currently spending millions of patient premiums to try and convenience us that they are in fact patient centered institutions instead of complex financial institutions created to reward shareholders. Big pharma is still big pharma. Doctors are caught in between the paternalism versus patient centered debate while still trying to care for their patients and not burn out. Hospitals, they are still worth millions while continuing to create some of the most exciting and spectacular fundraising parties ever seen. Then of course there is me, the chronic patient who spends a great majority of his life in pain that would send many to the emergency room but instead I must continue to work full-time then find any spare energy to try so-called “alternative pain management” techniques or face heavy societal stigma for using current pain management methods. Complexity is no ones friend in this case.
Through all this complexity and confusion, the American way dictates that all players that provide any service in healthcare, regardless of success or not, must get some form of financial compensation. After all, our country seems to put blind faith in capitalism which basically calls all of us commodities that can talk instead of human beings that feel pain, discomfort, sick, happy, love, excitement, or stable. Maybe we have all (as a collective) have become to comfortable with our Starbucks on every corner, laptops at every store, and ridiculously large houses when compared to the rest of the world. I don’t know what the answer is, all I do know is that until we undergo a fundamental discussion of healthcare that revolves around human rights and quality of life ideologies versus paternalistic capitalism we will always need new payment models that are basically knee braces for whatever the latest and coolest new care model someone develops is.
Current Healthcare Payment Models-
Just out of curiosity, I decided to Google “healthcare payment models”. In my professional life (my employer would like to stay anonymous), I deal with various healthcare payment models on a daily basis. My “professional” guess would have been that there are somewhere in the neighborhood of 3 to 5 different models out there. Of course there is the fee for service model most of us are familiar with, I know CMS and state Medicaid’s have their own payment models for their participants, then I figured there would be one for our rare disease patient friends. I was somewhat surprised when the first site Google gave me, www.mckesson.com, lists 8 different payment models in healthcare currently.
Since this post is ultimately going to be about my own healthcare payment model, I thought it would be important to provide you, my loyal readers, with some knowledge about the current models in our system. These 8 payment models come directly from the McKesson website that Google found for me. My “professional” guess is that this list is fairly accurate but I do not guarantee anything. This list is strictly for your general knowledge; please let me know if you know of other payment models.
Fee-for-Service – The most traditional of healthcare payment models, fee-for-service requires patients or payers to reimburse the healthcare provider for each service performed. There is no incentive to implement preventative care strategies, prevent hospitalization or to take any other cost-saving measures.
Pay-for-Coordination – Pay-for-coordination goes beyond fee-for-service by coordinating care between the primary care provider and specialists. Coordinating care between multiple providers can help patients and their families manage to a unified care plan and can help reduce redundancy in expensive tests and procedures.
Pay-for-Performance – In a pay-for-performance (P4P) or value-based reimbursement environment, healthcare providers are only compensated if they meet certain metrics for quality and efficiency. Creating quality benchmark metrics ties physician reimbursement directly to the quality of care they provide.
Bundled Payment or Episode-of-Care Payment – Bundled payments reimburse healthcare providers for specific episodes of care such as an inpatient hospital stay. This healthcare payment model encourages efficiency and quality of care because there is only a set amount of money to pay for the entire episode of care.
Upside Shared Savings Programs (Centers for Medicare and Medicaid Services (CMS) or Commercial) – Shared savings programs provide incentives for providers with respect to specific patient populations. A percentage of any net savings realized is given to the provider. Upside-only shared savings is most common with Medicare Shared Savings Program (MSSP) Accountable Care Organizations, but all MSSP participants must move to a downside model after three years.
Downside Shared Savings Programs (CMS or Commercial) – Downside shared savings includes both the gain share potential of an upside model, but also the downside risk of sharing the excess costs of healthcare delivery between provider and payer. Because providers are taking on greater risk with this model, the upside opportunity potential is larger in most cases than in an all-upside program.
Partial or Full Capitation – In this healthcare payment model, patients are assigned a per member per month (PMPM) payment based on their age, race, sex, lifestyle, medical history, and benefit design. Payment rates are tied to expected usage regardless of whether the patient visits more or less. Like bundled payment models, healthcare providers have an incentive to help patients avoid high-cost procedures and tests in order to maximize their compensation. Under partial- or blended-capitation models, only certain types or categories of services are paid on a basis of capitation.
Global Budget – A global budget is a fixed total dollar amount paid annually for all care delivered. However, participating providers can determine how dollars are spent. Global budgets limit the level and the rate of increase of healthcare cost. Global budgets typically include a quality component as well.
For those of you that are intrigued, barring a complete fundamental change in the basic philosophy regarding how we (our country) views healthcare, I believe that Accountable Care Organizations (ACOs) will be the new “it” payment and care model of our future. The simple reason for this belief is ACO’s are designed around the ideal of community healthcare.
ACO’s are defined as groups of doctors, hospitals, and other providers who come together in order to give coordinated high quality healthcare to their patients. The hope is to ensure that patients, especially chronic patients such as myself, get the right care at the right time, while avoiding unnecessary duplication of services and preventing medical errors. Sounds like the right idea.
To put it in patient terms, I would work with my primary care doctor in deciding a course of care for my current health conditions. My payer (my insurance company and I) would then provide a payment to my primary care doctor once a care plan is development. It would then be up to my primary care doctor to contract and work with whatever rheumatologists, pain management doctors, orthopedic specialists, and mental health providers that I require, for example, to arrange payment and compensation for their services. ACO’s keep my primary care provider and I as the head coach/quarterback and has the added benefit of keeping lines of communication open within all the providers that I need in order to raise my quality of life. Lets remember no idea will ever be perfect, that said I find the idea of ACO’s closer to perfect than say the current fee for service model we have now.
Alan Kristopher Brewington’s Excellent Care Model (AKB)-
As I’ve previously stated, there are currently at least 8 different healthcare payment models in our healthcare system. Logic would dictate that 9 healthcare payment models probably won’t change the current quality of care I currently receive or the lack of access to quality care to many patients are currently facing in our country. I would argue that you are probably correct, however, the AKB Excellent Care Model is the only payment methodology exclusively developed by a chronic patient so at the very least it deserves a read.
My AKB Model revolves around 2 essential principles. First, the patient owns all of their data. Patient Data is defined as anything from vitals or blood sugar levels to urine or blood needed for diagnostic testing. If it is produced, taken from, or created because of the patient they own it, not healthcare. Secondly, and most importantly, the patient comes first, not politics, ideology, paternalism, capitalism, etc. If there is a question, problem, or issue, all participants will refer to the patient’s wishes then work the issue from there. Design thinking revolving around the idea of how might we… will be required education for all providers, professional healthcare staff, executives, and health insurance employees. In the spirit of raising the quality of life of both acute and chronic patients, the idea of time is quality of life will become the mantra for all of healthcare, not time is money. People first, we will work out the business and profit end of the equation after the fact.
As a patient, I will no longer need insurance. In the AKB Excellent Care Model, everyone from “doc in the box” to specialists will pay the patient for their visit and continued visits. Patients will get co-pays from their doctors instead of the other way around. In exchange for payments, patients will essentially sell their data and future developments to doctors. Doctors and providers, who want to specialize in rheumatology patients like myself, will probably pay more than say a “doc in the box” that treats a wide array of acute conditions for example. This is not an absolute guarantee and will depend on a multitude of other factors.
Since doctors and insurance companies already have a relationship, they will now partner their resources (doctor with their direct access to patient data and insurance companies with their available cash from their financial investments) to develop studies and papers to sell to big pharma and academic institutions. Knowledge is a dynamic concept that is always developing and changing. The pursuit of knowledge, regardless if it’s defined as a success or failure, needs to be rewarded economically. The constant pursuit of knowledge is the key for finding much-needed cures, not someone’s judgment of said knowledge. History teaches us that the cure for my chronic pain will be just as likely discovered by accident or someone trying to cure cancer for example versus someone setting out to cure chronic pain.
Finally, I see big pharma and academia working with private industry to develop products and solutions to patient specific problems based on the knowledge gained from doctors and insurance companies working together. Big pharma and academia’s incentive to participate will come from the glory of developing ideas that affect patient’s lives almost immediately. The affordable ice pack that better forms around my knee or neck will be placed on the same level as the pill that suppresses my cough so I can go to work without scaring my coworkers. Providing human centered solutions for patients will be rewarded, not the creation of products just for shelves at retail stores.
Prices in the AKB Model will include a small factor of risk involved in keeping knowledge, experiments, and papers completely transparent and open. Pay walls will be subject to jail for billions of years. Knowledge must be thought of as a universal human right, not another commodity that needs restricted so market forces drive up the price. Under no circumstances will the AKB Model be a restriction to patient designers or developers. If a patient does not want to work with a doctor or insurance company direct, they will have the option of retaining the rights to their own data so they can develop as they see fit. These patients will still receive payment from their doctor, it would be less than what I would get if I were to sell all of my data for example.
First, the AKB Excellent Model of Care is a bottom up approach to healthcare and payment reform. It comes from a chronic patient, which means there are natural biases built into my idea. I’m not sure of where my idea would fall on a political spectrum, and frankly, I don’t care. My idea is based on the belief that continuing the conversation regarding healthcare reform will breed new ideas, which breeds hope and comfort with patients like me.
As a country, we need to remove these bumper sticker sound bites from ideas like healthcare reform. Part of the mistakes of Obamacare comes from the fact that the bill was to big for the general public to comprehend, I don’t have time to read and study a 1,000 plus page bill, most of our Congress doesn’t take the time to read bills a quarter of that size. Details and ideas got lost in the size of Obamacare unfortunately. If President Elect Trump truly believes simply repealing Obamacare can save healthcare then he needs to resign immediately and go back to the Real Estate game. This is a complex and delicate problem involving immediate life and death consequences from our choices as a country. The sooner we can admit this, the quicker we can prevent lives from being lost due to stupid politics or ideology I believe.
Finally, I wrote this haiku last week that seems to be the perfect way to end this post: