If Patients Determined Health Care Payments

Left to their own, health care consumers might well design very different delivery and payment arrangements for health care – and we can learn from this perspective. While providers often think of health care on a continuum, individuals generally think of themselves in just one segment of the system: healthy, acutely ill, managing a chronic condition or suffering a complex illness. In other words, a person will likely perceive the health care system as relevant in only one ambulatory, or out-patient, delivery domain.

People who consider themselves to be healthy may not see a reason to be “in line” with the sick, and they may not believe it reasonable to have their appointment delayed or interrupted by needs of acutely ill patients. They value convenience.

Those wrestling with an acute illness or concern seek the most rapid access and resolution. They will often trade anMiles Snowden, MD, MPH, CEBS Chief Medical Officer, OptumHealth established physician relationship for quick access elsewhere. Further, they do not believe it reasonable to have assessment of their concern delayed by interactions with the well or the well-controlled chronically ill. They value speed.

People living with a chronic condition often become expert in their own condition and treatment and have little patience for care providers less expert in their condition or less familiar with their care. They value the provider relationship.

Those suffering from a complex condition seek the highest level of knowledge and will sacrifice convenience, time and provider relationships for such access. They value expertise.

Given these health care consumer demands, as markets mature, the ambulatory delivery space may be shaped into four distinct retail lines of service:

  • Preventive Medicine – wellness services delivered by physician extenders (e.g., physician assistants or nurse practitioners) in convenient settings.
  • Acute Medicine – acute health concerns addressed by physician extenders in settings focused on rapid service delivery.
  • Chronic Care Medicine – rules-based ongoing management of non-complex chronic disease by care teams with physician managers in a consistent setting.
  • Complex Medicine – diagnostic challenges, procedures, complex care, care transitions and end-of-life services delivered by specialty service vendors (some with hospital, large medical group or retail pharmacy chain partnerships in centers-of-excellence style), delivered by respected service providers in necessary, but perhaps inconvenient, settings.

If we look further through the lens of the health care patient, we can see how these individuals might be inclined to pay for health care in this revised system:

  • Bundled payments for preventive medicine services (one payment for all services related to an annual wellness exam).
  • Fee-for-service for acute medicine services (paying only for those services needed to treat the current health situation).
  • Patient-centered medical home-based or gain/risk-sharing for chronic care medicine services (both patients and providers benefit financially from better managed conditions).
  • Episode payment for key areas of complex medicine services (a single payment that factors in multiple elements of ongoing treatment for a complex condition).

This might be how a health care consumer would construct payment reform. Might they be right?

3 thoughts on “If Patients Determined Health Care Payments

  1. Thank you for this hypothical consumer point-of-view of how the health care delivery and payment system should work. In your fairy tale world of health care, the delivery and payment system appear logical and concise. Wouldn’t that be a nice change to the current dysfunctional, extravagant methods?

    • Thanks for responding to our post. We’re also concerned with the complexity of our health system, and the resulting barriers not only to better health care services but to helping people make better decisions for their health. It may seem like a fairy tale today. Solving big problems begins with a vision. We’re dedicated to sharing our vision and working with our clients to be part of the solution.

  2. It is really fairy tale. It could never be come in use. I agree with the fact that patients who are suffering from chronic condition get more knowledge about their condition through suffering. But it doesn’t mean that they can treat their condition. Their condition can fluctuate and they cannot handle such situation. So it is always better to follow the instruction of your physician. But I like to say the treatment expense should be minimized.

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