Newtown, CT – May 3, 2013
Lourdes is a little town nestled in the Pyrenees mountains, on the banks of the river Gave, to which, every year, about 6 million pilgrims travel – of those, perhaps a third are afflicted with one or more illness; some are young, very young; some are old, very old. This weekend, a little over 1000 of those pilgrims will be from the US, and among them are 200 who need serious care. That care is provided 24 hours a day by skilled physicians and nurses who come as part of the pilgrimage. And on site are dozens of other skilled clinicians who can supplement needed specialty care at a moment's notice. What's remarkable of course, is that no money will exchange hands, no bills will be submitted, no commerce will interfere with the provision of services. This isn't exclusive to Lourdes, but perhaps it's more pronounced here than elsewhere, because of the way clinicians come to patients and not the other way around. Or maybe because the contrast is so striking with what happens back at home.
What this means to you – I've recently seen a resurgence of fee-for-service apologists, arguing that sticks and carrots won't work, don't work to motivate professionals, and they bring up good points, but miss a few essential ones. They miss the point that apart from a few instances, fee-for-service is incapable of bringing about the type of care we see at Lourdes. The volume-driven commerce worries about the number of tests and visits, not about the well being of patients. So while the physicians might want to focus on their patients, the commerce of fee-for-service drives them in the opposite direction. The second point they miss is that the core of incentives improvement is to find a way to get the commerce from interfering with the care, not to manipulate sticks and carrots. Some argue that moving right away to global capitation will do the trick, and for some — very few — organizations, that might be true. But for the vast majority, the commerce would simply take another form, rationing. So while you're designing new payment schemes, think about Lourdes, think about the selflessness of the clinicians who go to their patients at any time of day or night and how your payment model would help to replicate that for all patients. And above all, make sure you don't do something that will screw things up even more.
Francois de Brantes
Health Care Incentives Improvement Institute, Inc.