United Healthcare Drinks the Kool Aid

“UnitedHealth Will Tie Doctors’ Payments to Quality of Care in U.S. Shift” was the headline I saw during my morning review of medical news. The article describes in glowing terms how United Healthcare will save money because people will be healthier.

“UnitedHealth expects to save twice as much as it would spend on incentive payments for doctors because patients will be healthier, according to company documents ... The nationwide expansion of the program follows similar efforts by the U.S. government and rival insurers to trim medical costs by shifting away from paying based on the amount of services provided.”

The age-old argument of quality over quantity. Currently, the payment system in place is quantity. Providers are paid per CPT code billed, which defines either an office visit or a procedure performed. Medical notes, referred to as SOAP(S=Subjective, O=Objective, A=Assessment, and P=Plan) notes do not mention quality of care, only that care was delivered and the plan (if any) for continued care. The current guidelines to writing a SOAP define the exam, the chief complaint, what was examined, diagnosis and treatment. In situations of a chronic condition the provider can note if the patient is getting better or worse in terms of recovery, but this does not relate to the quality of care.

The argument to move away from quantity in terms of payment is that physicians are over-worked (a physician needs to see a minimum of 28 patients a day to make enough revenue to simply maintain a business) and patients are not receiving good care. Concierge medicine attempts to deal with this issue by limiting the number of patients a physician has by charging each patient a retainer to be their personal physician. A limited number of physicians have moved to this model, but it cannot be implemented with Medicare Patients: Medicare prohibits charging a patient more than the Medicare Fee Schedule for medical treatment. So, two solutions have emerged, ACO’s and payment for quality. ACO’s are a capitation plan which failed under HMO’s and will fail again, but quality is a new concept. The theory is that if a physician knows that he/she will only be paid if their care is high quality, then the physician will take the time to truly treat the patient. As with all theories, only practical application will prove their viability, but I do have some thoughts on the theory itself based on common sense and my experience.

Thought 1: People do not always do what is in their best interests. The Darwin Awards are a testimony to this thought. In medicine the physician is only as successful as his patient. If his patient is 200 lbs overweight, smokes, and has a steak for dinner every night, there is a high probability of heart disease or stroke. The physician puts the patient on a diet, enrolls him in smoking cessation classes and gets him a life time subscription to Veggies International. The physician provided quality care. But the patient ignores the diet, blows off the classes and sic’s his dog on the nice lady from the Veggie group. He has a stroke and is admitted to the hospital. Who is to blame for this situation, the physician or the patient? Under the quality mandate it would be the physician because his treatment did not prevent the stroke.

Thought 2: Pre existing conditions or genetic time bombs. Science has demonstrated that each of us have genetic markers that can become a myriad of diseases. The federal government takes this so seriously that as an employer I cannot discriminate against someone who has had a genetic test and came back positive for some chronic and life threatening disease. Even though that disease will cause my health care insurance premiums to sky-rocket, I cannot take that into consideration when hiring an individual. What if a physician takes on a patient that is unlucky enough to get one of those chronic, expensive diseases that have death as the only outcome? Will he not be paid because his treatment could not keep his patient alive? After all isn’t that the true outcome of quality care, staying alive?

Thought 3: Who defines "quality care?" In the 1980’s the argument revolved around the best care for a child, home with a parent or in a daycare setting. It was the same argument: the stay at home parent offered quantity time, while the child in daycare received quality time from one’s parent. That argument was not resolved because we all have our own definition of quality. In terms of medical care, is the fact that you did not die during your appointment prove quality care or is it keeping the person from ever getting sick or injured or suffering any bad thing from ever happening, (remember, even bad things happen to good people)? It cannot be answered, and if it cannot be answered then a payment system cannot be linked to it.

Thought 4: If the insurance company and/or government define quality and their definition determines if the provider gets paid, will the provider ever get paid? In medicine right now providers and insurance companies are competitors; competitors for the patient’s dollars. The insurance companies are a business and it is in their best interest to keep the money. The providers did the work and thus the money is owed to them. It is getting harder for a provider to be paid for treatment rendered simply based on the objective parameter of delivering treatment. How much harder will it be to get paid with the parameter as subjective as quality?

Based on these thoughts, it is my hypothesis that payment for quality care will fail because of one simple fact: We are mortal and no amount of medical treatment will alter that reality.