Innovations in Primary Care: Moving Beyond Fee-For-Service

The American medical system has long operated under a fee-for-service model in which only specific, narrowly-defined medical services qualify for reimbursement from insurance companies. This system is reasonably well-suited for procedure-oriented specialties in which services with clear indications, processes, and outcomes such as colonoscopy or knee replacement can be appropriately paid for.

In America’s fee-for-service system, reimbursement for primary care services is limited to short office visits and certain outpatient procedures (such as a joint injection). Many primary care doctors have felt that they could offer better care for their patients if the payment structure allowed for more flexibility in services offered, but opportunities to test this hypothesis have been limited.

Today, three groups in the Seattle area – Landmark, Concerto, and Iora – are independently demonstrating the value of flexibility in primary care to improve patient outcomes at overall lower cost. They’ve accomplished this by arranging for alternative payment models with local Medicare Advantage plans (private insurance plans who contract with Medicare to provide health insurance to seniors). Rather than operating under fee-for-service, these companies get a per-member, per-month payment. This payment structure provides a flexible budget with which they can offer services that don’t necessarily fit into the established fee-for-service structure.   Continue reading “Innovations in Primary Care: Moving Beyond Fee-For-Service”

Behavior change and patient empowerment

(The following is a response to an event co-hosted by NEJM Catalyst and LDI CHIBE on “Patient Engagement: Behavioral Strategies for Better Health.” It has been cross-posted to the Leonard Davis Institute’s Health PolicySense blog)

As a medical student going into primary care, I value health behavior change not only as a disease prevention strategy, but as a way of empowering patients. In many areas of our health care system, we ask our patients to be passive recipients of care: to take their pills obligingly, get their colonoscopies on the appointed date, and to consent to the surgeries we recommend. In health behaviors such as diet and exercise, patients are instead active promoters of their own wellbeing.

This altered power balance in which the patient has control and the provider has only influence can make health care practitioners who are used to being in charge feel deeply uncomfortable. However, with a third of all premature deaths in America attributable to health behaviors, there is tremendous opportunity here to better our nation’s health by partnering with patients to promote more healthy behaviors.

Continue reading “Behavior change and patient empowerment”

A Brief Intervention for Behavior Change

This essay is based on a talk I gave to medical students and faculty at the Perelman School of Medicine at the University of Pennsylvania on how physicians can help patients achieve behavior change.

Developing instincts

heart_attackThis image is enough for most of you in the audience to start building your differential diagnosis. When this older gentleman shows up in your emergency department sweating profusely and complaining of chest pain, you’re going to instinctively reach for an aspirin and an EKG.

Much of our medical training is focused on these kinds of situations where procedural memory helps us act quickly and effectively. This is important because when we’re in a time limited and stressful situation, it can be difficult to think clearly and so we need to develop good instincts.

Yet let me turn the clock back twenty years, well before his coronary arteries are overrun with plaque. What happens when this same patient shows up to your outpatient practice and during a routine exam you find out that he smokes a pack of cigarettes a day?

You’ve got 5 minutes until you see your next patient. Once again, you’re time limited and stressed. What do you do? Are you still ready to act?

Continue reading “A Brief Intervention for Behavior Change”