These changes can't be made by
pulling a lever on payment policy in Washington. I propose creation
of a public/private entity to reform healthcare, hospital by hospital
and clinic by clinic, involving both public and private insurers.
The operational plan is to create a voluntary group of linked high-performance hospitals and clinics in all regions of the country that would act as vanguards and examples of high-value medicine. This group would prepare the way for widespread changes in payment policy by Medicare and private payers. The American Medical Quality System would also determine the benchmarks for quality medical practice, the best practices needed to reach them, and develop payment systems that share the savings of high-quality practice with providers.
The five reasons for excessive imaging are lack of standards for a diagnostic work-up, lack of systems of care, improvements in the technology, defensive medicine, and the ownership of diagnostic facilities and equipment by physicians who refer their patients to themselves. Standards for diagnostic imaging, malpractice protection for physicians that adhered to those standards, and creation of systems of care would reduce imaging and improve the quality of care.
An ideal payment system would be to set a payment rate for a hospital and its affiliated specialists based upon the admitting condition of the patient adjusted for the patient's risk factors of developing complications. The payment would give efficient hospitals and doctors a comfortable profit margin but would force mediocre providers to improve .
The American Medical Quality System would provide the start-up capital to clinics that choose to participate in its payment experiments. Necessary start-up resources would be, for example, information technology and clinic-based nurse-collaborators.
Four steps could reduce the performance of unnecessary procedures and improve the quality of care without impairing a specialist's ability to care for a patient. First primary research to determine the effectiveness of procedures with enough detail to be applicable to the care of an individual patient. Second payment policy could reflect the findings. Third, patients could be required to review standard decision aids before undergoing non-emergency procedures.
Fourth, specialist's adherence to standards of practice and outcomes of surgery should be measured and reported.