Outcomes

If you are at all interested in the health care debate, read the New Yorker article by Atul Gawande on health care costs. He examines McAllen, Texas, a community that has Medicare costs per person that average $15,000. This is twice the national average and three times some of the lowest cost areas. His core finding is that these costs don’t relate to the relative health of the community or quality of care, or even bad administration, fraud, or waste. It is all about how doctors are reimbursed and the culture of medical practice in that area.

In our system doctors generally are reimbursed by procedure. Do an MRI and the cash register rings. Blood test, ka-ching. Colonoscopy, ka-ching. Sit down with a patient for extra time and discuss their medical history in depth, no ka-ching. Get advice from a colleague without referring the patient for a procedure, no ka-ching.

Gawande found that the hospitals with the lowest cost per patient were ones that set up cooperative structures for the payment of their doctors, encouraging communication and mutual assistance and discouraging excessive procedures. Patient health outcomes were just as good or better than high spending institutions.

Well, here’s a thought: reimburse doctors according to patient outcomes. That’s what we actually want, right? Not a number of tests, but an actual improvement in the functionality of our bodies.

Modern medicine is a numbers game, after all. When we enter the medical system we get interviewed, tested, and our condition quantified. Depending on the affliction, medical personnel might establish dissolved oxygen in our blood, range of motion in a limb, our heart rate response to exercise, or the concentration of any number of chemicals in any number of tissues. This is then compared to what is considered normal for someone of the patient’s age, gender, and general condition. There are also more subjective tests of comfort and range of abilities.

When reimbursing a doctor we should consider the condition of the patient at intake and compare that to the condition of the patient over a time period relevant to the common recovery period for the particular injury or disease. Add a difficulty factor, as in Olympic diving. During a transitional period we should slowly reduce reimbursements for procedures and increase an outcome bonus. We should distribute that bonus among a group of doctors that work with the same hospital or in a limited geographic area. That would encourage doctors to collaborate and also to police their underperforming colleagues.

The exact formula for this kind of reimbursement is beyond the scope of this essay and, frankly, beyond the knowledge base of your Minor Heretic. But doesn’t it make sense to reward our health providers for making us healthy, rather than making us endure yet another procedure?