Representatives from struggling rural hospitals in Maine have said in the media recently that they want to see their hospitals paid for the health of the local population, instead of for the services they provide. How would that even work? Also, has something like this ever been done before?
That would be similar to the work of a county health department or the CDC.
For example they will have programs to vaccinate the population. Or institute rules for food handling - that alone can prevent people from becoming sick - getting restaurants to be safe with food.
Vaccinations or isolation of “contagious people” can keep the rest of the population from getting sick.
Etc.
Note some states have proposed measures to not provide ANY medical care (including vaccinations) to illegal immigrants. But contagious diseases know no borders! The diseases do not see a legal citizen and suddenly stop in their tracks!
So the idea is to give vaccinations to everyone in a community - prevent disease ahead of time. This is a LOT less expensive than tons of people getting sick.
Part of the Affordable Care Act was shifting Medicare payments from quantity of care to quality of care, including patient health. Here’s the website for the program.
The OP may also be a misunderstanding of the federal Medicare Rural Hospital Flexibility Program that promotes the establishment and support of “critical access hospitals” and community health initiatives in rural areas.
Rural hospitals in Maine have received direct and indirect funding from this program as well as from other public and private organizations for this purpose. They’re financially stressed because so many major procedures are being diverted to large urban hospitals, and some have been talking about a greater emphasis on health maintenance and preventative services. But no one, anywhere, is talking about doing away with the normal fee-for-service health services model. The OP seems to have misunderstood what was being said.
It’s called socialism. Which will get you tarred and feathered in the USA.
The basic principle is to assure an attainable level of general public health, and direct community resources toward competent agencies equipped to meet that goal. (Condensing many long books to a single sentence.)
I was going to suggest Cuba … I may have my facts wrong here (and please correct my errors if you would) … but the Cuban government sends their best and brightest to medical school … brings them home and assigns them a few hundred people to care for … with orders to keep them healthy … using the “a pence of prevention is worth a pound of cure” model of health care …
The Maine State Militia can form a Medical Corps and just start drafting people until they have the 3,000 MD’s they’d need to pull this off …
The principle is the Ancient Chinese model: one paid one’s physician throughout the year, but not when one fell ill, because that was his failure and he’s got to remedy you to regain income.
However silly earlier and different medical systems may have been, none compare to the present US set-up.
Perhaps I should point out that, unless the OP actually has a cite to support what he claims, the OP is based on a total misunderstanding which has now morphed into taking the thread completely off the rails in a way that has nothing to do with reality.
Again, it seems that all that’s happening is that rural hospitals are under financial stress because so many patients are receiving major treatments at large urban centers, so they’re looking to change their service model to be more oriented to outpatient services and health maintenance and preventative services. That’s all.
I learned (in the documentary Sicko ?) that Britain’s National Health family physicians are compensated by how healthy their patients are — not, as in the U.S., by how many procedures they get to perform.
Well. -ish. GP practices contract with the NHS, and the terms of the contract vary from time to time, depending on the latest thinking/policy fad. But the basic principle is that there is a basic fee per person registered with the practice (to access the system, you need to register with a practice, or just take your chance at the hospital A&E, where you may get told you should have taken your boil/ingrown toenail/stomach-ache to your GP).
The amount of the fee is varied according to the local demographics (and there can be a lot of argument about exactly what those are, and how variations can affect specific practices if they change too wildly), and more recently there have been all sorts of supplementary adjustments to encourage GPs to spend more time and effort on various health priorities, like obesity, smoking cessation, pre-diabetes lifestyle advice, and so on. So in principle, yes, there is no financial incentive in the system to over-treat (nor is there for hospitals), but it is stretching a point to infer that GPs are funded solely or even mainly for preventive care and local public health.
http://content.digital.nhs.uk/article/6037/New-report-looks-at-the-NHS-payments-to-General-Practice
https://www.england.nhs.uk/gp/
I’m not in the health care industry but I once did tech support for software that did medical billing (as well as other things) and that sounds an awful lot like capitation.
That system isn’t new in the US, various health providers have been paid that way for many years.
That’s the basic flaw in the system. How do you “equalize” the assortment of patients? Superfreakonomics discussed the problem wrt judging performance of emergency room doctors. The best doctors may get the most challenging patients, so their success rate may be lower. It’s always a good idea to encourage proactive push of healthy lifestyles, but not everyone can always be 100% healthy.
In the NHS, you don’t equalize the assortment of patients. The physicians have no option to decline patients (except under unusual circumstances like having a violent or severely noncompliant patient); the patients choose physicians. There is a market force of sorts that allows better clinics to obtain more patients, since more people will register with them if they are well thought of. Conversely, crappy clinics see fewer patients, but this in turn allows their partners to spend more time with each one. There is also an equalization of sorts in that there are demographic adjustments to the reimbursement rate which account for, say, higher rates of alcoholism in the North. The NHS is not a pure capitated system.
Which is why there are risk-stratification adjustments built into many private payer capitation systems and as part of the Affordable Care Act.
Almost every care provider or group with poor scores I’ve ever met has claimed that they are taking care of sicker and more complex patients than everyone else is. Risk stratification tools allow them to get credit for that if they actually are (surprise, most who say they are actually are not). The main tool used is the hierarchical condition categories (HCC) diagnostic classification. Mind you I don’t follow the ways in which the scores are calculated but the bottom line is that if your group really is taking care of more challenging and complex patients and your providers bother to code appropriately you will be paid more than a group taking care of a less challenging population.
Anyway. The op is likely referencing either this article or something like it, which is discussing how rural hospitals in Maine hope to see the population health focus of the ACA become much larger. The move is clearly towards having healthcare systems work together from outpatient preventative care to outpatient sick care to inpatient care and back out again in a coordinated manner that provides the most value for complete populations. It’s just that right now they are stuck with a mixed system that still has more based on fee for service (which incentivizes hospital dominated systems to use hospitals for services more, even though in many cases the outcomes are worse and for more cost).
Rural hospitals, especially “critical access hospitals”, are hamstringed some too. First off of course there is the fact that many rural states have declined fully participating in the ACA. Plus individual rural hospitals have a hard time having a big enough population to make many of the pay-for-performance population helath metrics meaningful. They can form ACOs for the sake of pooling numbers but they really are not the coordinated entities that can formulate team approaches across their shared populations. Not that it is easy for any group. Basically it is asking hospitals to have a very large cultural shift. To work as part of integrated systems that will, if they work, result in their being used less? A big ask.
But yes some ACOs are delivering excellent value on risk-stratified population metrics.