The New England Journal of Medicine** publishes a doctor’s lament on practice restrictions:
Many strategies for the containment of medical costs have emerged from systems of managed care — gatekeeping by a primary care physician, prior authorization and utilization review, assumption of financial risk through capitation payments to the provider with financial disincentives for hospitalization or referral to specialists, and so forth. But another feature has crept into the managed care formula and has been largely overlooked: that of slowing and controlling the use of services and payment for services by impeding, inconveniencing, and confusing providers and consumers alike…
This is a common complaint. A bureaucrat gets in between a doctor, their decision making and the patient’s best interest. This comes in many forms. The big ones are payment reform efforts that shift risk to provider led entities for the entire episode or global budgets for a given population instead of individualized widget payments. All of those introduce financial criteria into what should only be clinical decisions.
The ACO models are proliferating. Bundled payments are becoming more common. HMO gatekeeper models are quite popular on the Exchanges. There is an imposition of another layer of complexity on clinical decision making.
In some ways, there is very little new in health policy. Most things to contain costs have been tried at some point, they worked to some degree and then push back happens as the way to control costs is to have the payers maintain a credible threat to say either “No” or “No, not at that price”.
This complaint is from 1989.
ACOs are mostly a repackaging of the provider led HMO model with better data analytics and risk adjustment.
Global payments are supersized capitated payments.
HMO’s are HMO’s.
EPO’s are HMO’s with fewer gatekeepers.
There is very little new, just different ways of applying the same few incentive structures to different chunks of the system.
** N Engl J Med 1989; 321:607-611