A complete novice refutes the statements of a qualified professional

Why I oppose payment reform- Alan Weil, Health Affairs Blog

Interesting article but I’ve got counterpoints ’cause I’m a student with more opinions than I have a right to and am cocksure enough to comment on statements made by the editor-in-chief of Health Affairs.

Summaries of his points are in bold. Please read his article regarding opposing payment reform in health care to get his full and well considered arguments.

The current workforce is unprepared for a model that doesn’t reward for filling beds, doing tests:

  • There are tremendous rewards for innovation in the field of health care right now! These folks have seen the model they came up in become more and more of a frustration to them and their patients. Everywhere I look, from floor staff to executives, the feeling is very get on the train folks, we’re heading to the future. Alternately: retire, find a different gig, or learn to cope with the new requirements. People are learning to become successful and you better believe that new leaders are prepared for these challenges.

Any money saved will move its way to the top (health systems, hospitals) and workers on the front lines won’t see any benefit:

  • Maybe. Based on the ones I’ve spoken to I don’t think dietitians, social workers, and community health workers are expecting a huge raise. But many hospitals are dramatically understaffed in these positions to the point that they are unable to perform the core competencies of their roles. As these workers bring forward evidence showing the financial benefit to hospitals of having, say, a full time dietitian to improve nutrition and reduce pressure ulcer rates, hospitals will have a financial reason to staff these professionals.

There is no current evidence to suggest that payment reform will achieve the goals we need it to achieve, and there is some evidence to the contrary.

  • Okay, your evidence is good here, but early days! There is evidence showing smaller programs put into place are already saving money such as reduced re-admissions with heart failure transitional care (article unfortunately not open access, DOI: 10.1097/JCN.0b013e31827db560).

The original rationale offered for payment reform doesn’t match the current objectives.

  • I think it does match that original rationale (to pay for quality rather than quantity of care). Health systems do not have an incentive to stop a practice for which they are getting reimbursed. We know patient falls are bad thing for a patient, but more days in the hospital to recover from your now necessary hip surgery is money in the hospital’s pocket. Why would you spend money reducing falls to stop yourself from making money? When hospitals are told they won’t be getting paid for the consequences of that fall innovations in care happen and adverse event rates go down. Of course we need metrics to quantify success and failure, and because these rule changes are rolled out in a way that intends to give health systems time to introduce new measures without sinking the rusty old tub. And certainly hospitals with higher acuity patients are getting the shaft, hence even more complex models to try to even the playing field.
Payment reform poses a risk for the growing understanding of the importance of patient-centered care (What is an appropriate value formula when patients differ in their goals for recovery).
  • The value formula is simple: “Patient, are you satisfied that you have reached your stated goal of x?” If your 95 year old patient states his goal is successfully completing the Marine Corps Marathon pain-free then you’ve got to use your negotiating skills to get him back on this planet. The point is to set patient centered appropriate goals before undertaking invasive or potentially harmful interventions.

3 thoughts on “A complete novice refutes the statements of a qualified professional

  1. It may be a little early to claim refutation, but who knows, you might convince me yet…

    So let’s take your example of the 95 year old patient who wants to successfully complete the Marine Corps Marathon pain-free.

    You dismiss the patient’s goal and suggest that other health care professionals and facilities will need to negotiate a more realistic goal.

    What right do you have to dismiss any patient’s goals? What right does any health care provider to arbitrarily decide what services and procedures a patient may want or have or what services the health care provider must furnish?

    It is, of course, nowhere near as easy to decide what services a patient is entitled to as you suggest.

    Now let’s get a little more real. Suppose you have a 95 year old patient. Is the patient active? Perhaps the patient drives a car, plays tennis every day and has been running in marathons for the last 40 years. Your 95 year old patient wants a new right knee which is how the patient believes (s)he can complete the marathon pain free.

    How does this play out with various payment reform models?

    Under a fee for service payment system the patient makes a decision based on what they want, what their co-payments will be and health care providers are only empowered to treat your, or not.

    We both agree that this is not a perfect system. You may know some people that are providing such care who would do a knee replacement on a patient with Alzheimer’s who has already had an above knee amputation. Not a good approach? Yes, we can agree on that but probably for different reasons.

    How about a capitated/managed care primary care physician and a very healthy 95 year old? This provider is going to face a huge and ethically conflicted decision. The standards of care don’t include exceptional treatment for exceptional patients. .The key to managed care practice is to see the average level of care as a maximum level of care.

    On this basis a physician/nurse/surgeon knows, or damn well should know that when they get their pmpm payments they ARE their patients’ health insurers. The patient wants the new knee. What little data exists for knee replacements in 95 year old patients looks pretty bad. Most die before becoming ambulatory.

    Can the patient have the knee replacement? Who decides? If the primary care physician is a new doc in a managed care practice their ability to continue in the practice will be determined by what it costs to provide the knee replacement.

    Should the physician refer the patient to an orthopedic surgeon or should the physician try to dissuade the patient from seeking such care?

    If the physician honors the patient’s request the average costs for managing their patients’ care will be far above the levels of other physicians and in many practices a single such referral may lead to being dismissed from the practice.

    Would YOU, as a physician who’s continued employment rests on your decision explain to your patient that they are highly likely to benefit from a new knee and would you, if you deny this care for the patient’s knee replacement explain that your professional and financial success hinged on being able to dissuade them from the care they wanted?

    Almost no physicians are making the decision to reveal their conflicted economic and ethical position.


    1. The example of a 95 year old wanting a knee replacement to run a marathon was meant as hyperbole. The provider of course does not get to choose what care is appropriate for the patient, but I believe we can do a better job understanding a patient’s goals and realistically explaining the likely outcomes of therapies and procedures. I believe the patient and provider should be partners.

      I agree very much with your points about the problems with fee-for-service models, and the ethical issues faced by physicians in recommending or dissuading a patient from a plan of care (as reimbursement and cost are opaque factors). In our health system we want so much to hang on to the option to have whatever type of we want, i.e. no rationing of care. Encountering an exceptional patient (the 95 year old who risk benefit comes out in favor of knee replacement) is a concern, of course.

      I know that primary care providers are being put in a very difficult position financially and in terms of getting to do the good patient care they want to do, by health care reform and managed care before that. I am not well versed and very interested in finding out more about this. Do you have any sources I could go to? Thank you!


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