By Dr. Lester Hartman
I remember the bad old days. By which I mean, I remember the 1990s era of “capitation” and all its ills — the rigid HMO spending limits that made money come between patients and their physicians.
But I’m not scared that they’re coming back.
Some worry that the coming “global payment” phase of Massachusetts health reform — in which health care providers are put on annual “global” budgets for each patient’s total care rather than paid for each procedure — will mean a return to capitation.
That would be terrible. As a pediatrician of 25 years, I remember the problems with capitation. It discriminated against special-needs children. It drove a wedge into the doctor-patient relationship, creating conflicts of interest by making doctors responsible for controlling costs. Access was restricted. Chronic disease management was not a priority.
But I welcome the impending era of global fees. If the concept of the Medical Home is incorporated — with its family-centered care incentives and rewards for innovations that save families money and time as well as improving quality — it could work.
Some see global payments as “capitation in sheep’s clothing.” However, if negotiated properly, there can be enormous opportunity for physicians to unleash their creative skills as never before in collaboration with families. It could be an opportunity to empower and educate families to manage more of their own minor health-care issues if they so choose — and as their deductibles increase, they will so choose.
Also, in our current system, insurance rate increase are coming more and more out of families’ pockets, not employers. Will there be a day when they just simply can’t afford going to the doctor? We need to act!
My practice, Westwood-Mansfield Pediatric Associates, is preparing for global fees. In our office, the most common reason for an illness visit is a sore throat. We responded to this by giving patients (at certain routine check-ups) a free home strep test to be used if certain criteria are met, with the proviso that patients must be seen in the office if the home test is positive or if the individual is not feeling better within 48 hours.
Since 65%-75% of rapid strep tests are negative in our office, we have been able to reduce office visits for sore throats by 20% and replace them with healthy lifestyle visits for overweight children.
We also give a prescription for a course of oral steroids, along with a written “Nighttime Asthma Attack Plan,” to parents whose children have asthma and instruct them on how to manage an asthma attack in order to prevent an ER visit. In addition, we have produced and posted, ourselves, videos of many common problems and how to avoid the emergency room.
The old fee-for-service system has stifled our capacity to be creative. The existing categories of services that can be billed for has also contributed to these barriers. Our own fear of change also plays a role.
The late Steve Jobs and Apple have been successful because they have been able to give people what they want before they realize they need it. This is what we strive to do. By empowering families to manage minor illnesses themselves (through patient handouts, websites, YouTube videos, and even “Apps”) we can shift the focus to the top health care problems of children – obesity, asthma, ADHD/learning style issues, mood disorders and allergies. In this model pediatricians can have a very rewarding job and make a good living.
Ultimately, the fact is that pediatrics has changed, and we have to change with it. Immunizations have eradicated most serious infectious diseases. Pediatrics must redefine itself as a specialty focused on wellness, seriously ill children, and chronic disease management and less on volume.
We can work on the concept of the Medical Home to improve care for our families in a team-based manner. In market terms, we need to give parents more value for either their co-pay dollars or their deductibles. Empowering our families is where our value will be coming from in the future, and global payments can help us get there.
Dr. Lester Hartman has such a tendency to push the edge of the practice envelope that WBUR’s Martha Bebinger reported on his work here, and he is featured in our technology post above.
He is a senior associate at Westwood-Mansfield Pediatrics, a Masters in Public Health candidate at Harvard and vice president of the Haitian Organization Program for Education and Health.