I work at a state Medicaid agency that’s planning to cut payments to doctors who can get that dough back by improving their patient outcomes. It’s generally called “paying for value.” Its opposite, “paying for volume,” pays docs for the number of services they provide, rather than their patients’ improved ability to bike to the river.
Clearly we need to pay for health care quality instead of for however many brains one can stuff into an MRI machine.
But we also know that social factors–jobs, education, immigration status, housing and food security–determine up to 80% of a person’s health. Not their doctor. Not their genes. Not their kale smoothies or meditation apps.
So paying doctors for outcomes may not make much sense for doctors who primarily serve people with low wage jobs in polluted neighborhoods and generally live without the kind of accumulated advantages that allow me, for example, to hit the bookstore for something to read on the airplane, which I’m flying tomorrow to a small town with a fantastic pastry shop and a famous theater.
Dhruv Khullar points out that scoring doctors who take public insurance against doctors who don’t, and paying them less when their patients inevitably can’t manage their chronic conditions as well, will probably result in lower-income people getting worse care.
And we haven’t yet figured out how to use the health care system to address people’s actual health needs: food, safe and secure housing, child care, decent wages.
I’ve been saying this around the office for a while, that value-based payments may punish doctors for poverty the same way that teacher evaluation systems punish teachers for poverty.
But Dr. Khullar is a doctor published in the New York Times, and I’m a pee-yoo-rocrat blogging for about 3 readers (hi guys!).
So not that I can do much about it, but I’ll spend my Fourth of July thinking about how to leverage health care funding streams to mitigate social inequity. Also cake. Happy Fourth.