Medical Musings

I was thinking about fee for service medical care and how it incentivizes “churn” or seeing many patients per day.  I was also thinking that I value my colleagues who do episodic care because I actually don’t think it’s necessary for my patients to be able to see me for every minor thing.  However, I also have a feeling that my seeing a patient for their list of five chronic conditions and my colleague seeing a patient for a sore throat are not the same complexity of visit and should not be remunerated in the same way.  Many capitation systems reward attaching young healthy patients and punish physicians when their patients seek “in basket” care from other providers (see the FHO system in Ontario).

So my proposal is this.  Incentivize patient attachment.  Create billing codes to incentivize care of complex patients.  Incentivize care of patients within the medical home.  Make episodic care less attractive to providers than comprehensive care.  Invest in diverting non-emergencies from the emergency department.

1. Patients receive a health spending account from the government.
2. Patients who sign up to be on a provider’s panel should generate multidisciplinary team funding according to their complexity score (based on age, gender, medical conditions etc.) – see Alberta Primary Care Networks, sort of.
3. Patients seen in their medical home – by their provider or another provider – are eligible for a full fee for service visit.
4. Periodic health exams and comprehensive care visits are only billable within the medical home.
5. Walk in clinic visits are billable at a lower rate than medical home visit but the walk in clinic may charge an additional fee (up to a legislated maximum).
6. All major emergency departments should have a co-located 24 hour walk in clinic run by salaried physicians.  CTAS 4 and 5 emergency department cases should be directed to this clinic or to follow up in their medical home instead of being seen in the emergency department.  A  patient co-pay would be required for CTAS 4 and 5 emergency department visits, whether seen in the ER or in the clinic.

This system incentivizes attachment.  It disincentivizes unnecessary emergency department visits. It attempts to be neutral to independent walk in clinics who provide an important function within the medical ecosystem.