专家应该按服务收费吗?

按服务收费模式是如何产生的?

曾几何时, 传说说, 如果你付不起医生的现金, 你可以用谷物之类的商品来支付他, 鸡, 球芽甘蓝, 或牛奶. Whatever goods or currency were exchanged, we called this model “fee for service.“几十年来，它一直是 美国医学的主导模式, 和 it defines the patient-doctor interaction as fundamentally transactional: the doctor gets something in return for the advice/diagnostics/prescription/procedure she provides you. So historically the way to increase your income as a doctor was to simply increase volume: the more patients you saw, 你赚的钱越多.

质量通常是衡量的, 如果有的话, 病人复诊的可能性. 在可能伤害患者的情况下, doctors tried to hold one another accountable by reviewing peers’ cases 和 participating in meetings such as “Morbidity 和 Mortality” (M & M)会议抓住明显的错误. Working within a model that so rewarded 数量 of care over 质量 of care, 这一点也不奇怪 医生可能会错过一半的指示性护理，或者介于两者之间 五分之一 和 第三个 医生所提供的治疗可能根本就没有被提及.

重质轻量

我们正在逐渐摆脱“按服务收费”的模式.“根据2015年医疗保险准入和CHIP再授权法案(MACRA), 罕见的两党法案, doctors can earn significant bonuses or incur significant penalties from Medicare by meeting or failing to meet certain benchmarks of 质量 of care.

长期以来，我们一直在尝试头戴式手铐 医疗保险的优势 plans that seek to incentivize private insurers to find cost savings 和 质量 opportunities. 和 大约一半的赔付来自私人保险公司 are now thought to be tied to some degree of value-based payment, or “pay for performance.“这一变化的目的不仅仅是为了激励 数量 我很在意，但是 质量 也.

We’ve even seen a modest rise in doctors operating outside the insurance system in so-called “直接初级护理”实践. These doctors ask for a modest recurring fee—usually $50-$100 per month—in exchange for unlimited access, with the underlying assumption that by limiting their patient panels (in part by eliminating administrative overhead), 质量必然会提高.

专家应该按服务收费吗?

It was in this line of thinking that investigators recently undertook an 检查与加拿大专科护理相关的费用. Canadian specialist physicians seeing patients with diabetes 和 chronic kidney disease can be paid under an American-style fee for service system, or they can be salaried with potential benefits tied to the 质量 of care they provide. *D披露:Justin Moore，医学博士，是一名经过培训的糖尿病专家*

Researchers compared the costs 和 质量 of care associated with each one, 和 the results were surprising: diabetic patients were 12% more likely to have a hospital admission or an emergency department visit for a diabetes-related condition if they were seen by a salaried physician rather than a fee-for-service physician, 尽管差异在统计学上并不十分显著(1.63 admissions or visits per 1000 patient-days in salaried docs vs 1.47(按服务收费的文件).

A lazy interpretation of this might lead you to believe that the salaried physicians, 薪水有保障, 只是没有经常去诊所看病人. But the researchers actually found the opposite: patients seen by salaried docs had 13% higher rates of follow-up visits 和 procedures (和 their associated costs) than the fee-for-service docs, 虽然再一次, 这些数字没有达到统计学上的显著性.在受薪医生中，每1000个病人日有74次就诊，而在受薪医生中则为1次.(54宗收费医生诊症).

From this data–admittedly in a Canadian system that differs in many important ways from our own–作者的结论 that “It would appear that salary-based payment does not have the same association with reduced 数量 of care provided for specialist physicians who treat chronic diseases as it does in some primary care settings.”

从这项研究中得到的教训似乎是, 就像经常发生的那样, 我们应该谨慎行事. 而 primary care may be in some ways best delivered in a salaried model, for now a fee-for-service payment model may remain preferable in specialty care. 在设计你的福利时, or when thinking of innovative ways to contain costs in your high-utilizing employees, 这可能值得记住.

图片来源.