Rejecting the Fee-for-Service Model

June 23, 2016 Cheryl McKay, PhD, RN

I’m a mid-level healthcare provider. I’m incentivized by a fee-for-service and procedure-based reimbursement system, which makes me reactive by nature.

That means I don’t heroically seek out at-risk healthcare consumers and hold an intervention when I spot them. 

I’m not a concierge who checks on my guests each morning to see if there’s anything I can do. 

No, I’m a maintenance worker who comes up to unclog the drain only when my guest needs it, and only after they’ve made an effort to come to me. I then tell them what action I’d recommend, based on best practices and my experience with what’s worked for other guests.

The healthcare industry has managed its populations with this reactive model for a long time, and business has been good.

But with the widespread fall of the fee-for-service model, that’s about to come to an end.

The jig is up

With the rise of the value-based model—where it’s all about the value a provider offers, not the number of patients she sees—and the demands of an aging population of unprecedented size, I’m going to have to accept that, in fact, a truly proactive approach to delivering healthcare will soon be the incentivized approach.

So if I want business to continue to be good, I’ve got to stop waiting for my customers to call the front desk, and I’ve got to start watching for opportunities to see if there’s anything I can do.

I’ve got to embrace technology like never before, truly manage my population, identify which patients might be at risk, provide innovative options that they probably aren’t aware of, and do it all while engaging my patients to actively care for themselves to the best of their abilities.

Here are five ways I, as a mid-level healthcare provider, might do that.

  1. Use analytics. I can find out who in my population is at risk for something that’s preventable by using analytics. This includes using data to predict recurrent episodes of hypertension or relapses of weight gain following a supervised weight-loss regimen; reviewing information collected from wearable devices to predict whether my patient’s condition has stabilized or is apt to degrade; and isolating distinctive data patterns—like medications used and biometrics gleaned from wearables—to avoid kidney failure, complications, and dangerous drug interactions. 

  2. Coordinate care. I can give my practice the technology that ensures not only that the right providers on my staff are managing the right patients, but that the entire staff is focused on their core competencies. I can ensure that my medical assistants are answering calls and handling essential tasks, my care coordinators are managing telephone and office visits, my physician assistants are handling routine patients, and the bulk of my time is allocated to managing patients with complex needs. 

  3. Create alerts. I can run a report on a specific cohort (e.g., male African-American patients between the ages of 50 and 75 with a family history of bladder cancer, female Caucasian patients between the ages of 40 and 55 with a family history of fibromyalgia, etc.) and inform them all of a new preventative test as it becomes available, even if they’ve never shown any symptoms. And I can even tell them which laboratories in their neighborhoods can administer that test right away.

  4. Manage referrals. I can ensure that my referrals are properly managed, only send patients to in-network providers, tweak those referrals as new data becomes available, and optimize the process to ensure that my patients are getting the best care. For example, the data might indicate that one gastroenterologist has a track record for positive outcomes for Chrohn’s disease, while another has a proven talent for esophageal and swallowing disorders. It will be because of this data that I won’t simply send all of my patients to the one gastroenterologist who’s been a close colleague for years. Instead, I’ll send my patients to the right gastroenterologist, even if I have no real relationship with them.

  5. Enhance quality. Ask any clinician and they’ll tell you: there simply isn’t enough time to review entire patient health histories and stay up to date on the latest findings for every health issue that presents itself in their office. But that doesn’t mean I shouldn’t seek out ways to allow that data to inform my decisions. I can do that by using technologies that isolate relevant, accurate information and deliver it to me instantly without significantly interfering with my ability to deliver treatment. For example, I could set up the most mission-critical alerts mentioned above to be delivered via text message, rather than via email. Or I could require text replies to be returned on my part so that if I somehow miss an alert, one of my staff will be notified to march into my office and apprise me directly. 

An opportunity for the taking

The fading fee-for-service model still dominates healthcare reimbursement today, but there’s no denying that customers are learning to expect more. They don’t want their clinicians to be maintenance workers who are waiting to help out only when the patients themselves summon them. They don’t want to ask their doctor if a much-hyped drug is right for them. 

No, they want their clinicians to be concierges that the patients can feel confident are looking out for their best interests, spending less time running a business, and devoting more time to being the innovative, imaginative caregivers whose offerings represent the unique sum of their passions, personal beliefs, and professional experiences.

As a mid-level healthcare provider, this is my opportunity to disassociate myself with the cynicism of a fee-for-service and procedure-based reimbursement system. 

This is my opportunity to stop answering calls with, “How may I help you?” and start initiating calls with, “I’ve got something for you.”


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