Those in the provider community might say, we tried to change the game in the ’80s and ’90s, and it didn’t work. So when it comes to balancing payment reform with putting the patient first, why do we play the same game if we get the same results?
There are fundamental differences between then and now, says Patrick Conway. The majority of the transformation that we see now is provider/physician/clinician driven — and the majority is voluntary. But he thinks we have some work to do with patients, adding that he doesn’t think we’ve done a great job of explaining what this actually means for real people.
“But I think our approach is quite different in terms of really having it be driven by the delivery system,” Conway adds. “And this one we’re going to need to continue to monitor, because if we go too far in the other direction, it doesn’t feel driven by the people in the delivery system, including the patients and providers, and it could have a real negative pushback.”
François de Brantes explains that one area where we failed the last time around is that by reforming payment, we failed to reform benefit design at the same time. “We created a perfect environment for conflict between the patient and the provider,” he says. For example, in the old days of “HMO $5 all-you-can-eat buffets,” patients will choose extra medical care, such as lab tests, because it’s no difference to them. But the provider, appropriately, doesn’t want to give that test because it might be unnecessary, says de Brantes.
“So you have a conflict. And this time around, that’s really a big difference because at least in the commercial sector, the volume of co-pays, the cost-sharing that commercially insured client members have to dish out, really does [create], from many perspectives, a better convergence between the patients’ interests and the providers’ interest,” de Brantes says.
But we also see zone detention. “For example, you can emphasize preventative care — that’s fine, because it’s covered in full. Secondary prevention is a big problem, because of course if the providers are held accountable for excessive ED visits or hospitalization of a patient because it’s a complication, then they’re going to want their patients to be more compliant, they’re going to want the lab tests, and the patients have to pay for all of that out of pocket.”
He adds that this is a growing concern in the commercial sector, because if we don’t figure that piece out, then the conflict remains between the provider, who is deliberately trying to deliver better care to the patient, and patients feeling as though they’re getting “sucked in” to doing a test that they don’t need.
To that end, de Brantes agrees with Conway that we have to do a far, far better job at trying to explain to people what all of this means.
From the NEJM Catalyst event Care Redesign: Creating the Future of Care Delivery at Kaiser Permanente Center for Total Health, September 30, 2015.