“Why shouldn’t I order that mammogram?”

The physician on the case wanted to catch the patient up on some health maintenance. She had failed to get the mammogram recommended, was in the hospital for an unrelated issue, and was here anyway.

The medical director tried to talk him out of it. In a DRG paid hospitalization, the mammogram would not be part of the DRG payment, and would not be compensated for in the DRG calculation.

Every dollar spent on unrelated diagnostics meant a hit to the bottom line for that stay for the hospital, which was struggling to make ends meet. The physician was thinking about the insurer, who was paying him incentives for assuring his patients got all their health maintenance. Not to mention the patient, who was behind!

“Doc, I can’t go home today, my daughter is getting in tomorrow, and she is helping me when I get home,” the patient said.

“But you’re not in need of another day in the hospital!” the physician responded.

“Well, I’m not as strong as I think I need to be,” countered the patient. “Another day of rest and therapy would really help!”

“We’re forming a task force to deal with those issues you’ve been complaining about,” said the hospital administrator. “We want to move quickly, so we’ll be having weekly meetings at the hospital for the next three months. Can you block yourself out of office hours so we can work on that problem?”

“But you’re paying me on an RVU basis,” countered the physician. “My patients need me, and I’ll fall behind on your demands that I meet my RVU quotas! Plus it’s a half hour drive to the hospital!”

“Thanks for working with us here in the ER, but I really need you to order more tests!” said the hospital administrator.

“Have I missed anything?” asked the physician. “Has the care I’ve delivered been substandard in some way?”

“No,” the hospital administrator responded. “But we make money in the ER on ordering tests, and you don’t order as many as the other docs.”

“You’ve been ordering more CT scans than anyone else in the ER,” said the hospital administrator. “We really need you to take a look at why you do that!”

“The patients demand it,” said the physician. “They want the CT scan and come in demanding them. I’m afraid I’ll get sued!”

Wouldn’t it be nice if …

• The needs of the patient were the absolutely primary driver for care?
• We could deliver care the best way we thought possible, without concerns for how the rules exist for payment?
• We could somehow stop unnecessary care being delivered by our colleagues more interested in making money than caring about patients?
• We could put a patient in a different kind of setting where you could quickly and efficiently work up that problem, even if they aren’t “sick enough” to be in the hospital, when you know they will never get what they need without being captured inside a care center?
• We got paid for providing the best care and getting the best outcomes, not for seeing the most patients or doing the most (or the least) number of tests?

That’s what the volume to value payment transition is all about. The devilish details of how that transition happens, and what criteria is used to define quality and how dollars are attached to them is what is going to drive us all crazy for the next few years.

The cynics will say it will be done all wrong. The supporters say it is the only way to control duplication, waste and unnecessary care and decrease the growth in spending.

The system is broken. We’re all bright people! What do you think we need to do? How do we control costs, stop abuse and duplication? How do you pay us fairly for doing a good job, and what should happen if we don’t do a good job?