CJM3:

You want prevention? By all means, I agree that it would be a better thing than to treat catastrophic conditions. But don't tell physicians that they should be reimbursed based on their ability to prevent an outcome that is almost exclusively outside of their control. Instead, a far more powerful motivation will be to CHARGE PATIENTS who do not comply with recommended lifestyle changes.

It is quite true that physicians are unable to control patient adherence to lifestyle modifications and other treatment recommendations. However, reimbursement could just as easily be tied to preventive effort. By documenting advice for controlling cholesterol levels and hypertension, for example, as well as agressively screening for those and similar known risk factors and controlling them early, the odds of preventing progression of disease can be increased. Not all of those efforts will be successful in terms of the end goal of prevention of disease, but as the Great One once said, "You miss 100% of the shots you don't take." If we reach even one in ten at-risk patients on these risk factors alone, we can go a long way to reducing the rate of adverse outcome from cardiovascular disease. Just imagine reducing the incidence of MI by 10%. The cost savings to the healthcare system would be enormous.

I'm not suggesting sweeping changes to the way that medicine is practiced (not yet, anyway... baby steps first). Begin by reimbursing more generously for existing screening measures (and easing the reimbursement threshold for those measures). Elevate reimbursement for E&M codes 99213 through 99215, as these core primary care codes generally involve servicing diagnoses that could respond to aggressive preventive measures (in our practice, at least). Tie that increase to preventive focus, if you wish, or expand allowable circumstances for using the -25 modifier to include preventive counseling and screeningas a distinct billable service. Mandate universal full coverage for an annual preventive care visit for all patients. Small measures such as these could begin to change the momentum, and would begin to make prevention an economically viable way to practice medicine.

The problem remains that insureres do not calculate risk on a long enough time scale. Most patients will be insured with numerous companies over their lifetimes. One study (abstract can be found here: <link>) found that 50% of patients changed insurers within 2 years, with fewer than 15% staying longer than 8 years with a single insurer. This turnover leaves insurance companies with no financial incentive to be concerned about prevention. When faced with a model of reimbursement that provides the greatest long-term benefit, they see only a potential increase in their near-term costs. Unfortunately, this short-horizon model for maximizing profit by minimizing cost results in greater costs for the system as a whole.

This, too, must change if we are to effect any meaningful reform of our healthcare system.

A way to make this more cost-effective for insurers would be to do as you suggested, and charge patients for non-adherence. Patients who fail to see their doctor on a regular basis in order to avail themselves of such preventive services, once they are actively encouraged and reimbursed, should be charged higher premiums. This would pass the greater costs to the system incurred by their failure to address risk-reduction on to the person most directly responsible.

Of course, this would promote a model of personal responsibility that is rather out-of-fashion in our society. However, that model also represents a much-needed paradigm change in our national attitude toward healthcare. By promoting personal responsibility and active involvement of the patient, and making them realize the importance of their actions in the care of their health, we can make them realize that they are the true stakeholders in the rising cost of healthcare in this country.