新聞與評論

看來Pay for quality這個政策也將在美國推行。即使以質計酬的政策可以在美國、英國推動，但是在台灣的病人就醫習慣下，恐怕困難重重。以質計酬的前提是能夠量化醫療品質。

在英美，民眾就醫受限，看病時醫師選擇有限，也通常是固定一個家庭醫師(GP)，前往醫學中心就醫必須經由家庭醫師轉診。在固定的一個醫師重複就診，就能夠以病患的outcome來評估GP的醫療品質。

而台灣民眾就醫自由，小病（流鼻水、咳嗽、拉肚子…）去診所(GP)看，發燒4-5天就直接到大醫院看。就醫過程中，摻雜多個醫師的處置醫療，或是心臟病看A醫師、糖尿病看B醫師，彼此之間的醫療交互影響，這樣就難以病患的outcome評估醫療品質。

在台灣除了實行DRG外，要像英美一般實施以質計酬的誘因，困難！

Medicare System Overhaul Proposed by Two Senators

Published: April 30, 2009

WASHINGTON — Leading senators from both parties said Wednesday that they would make sweeping changes in Medicare to reward or penalize doctors, hospitals and nursing homes according to the quality of care they provided.

The proposals, the opening salvo in a broad effort to overhaul the health care system at the urging of President Obama, would also create strong financial incentives for doctors and hospitals to coordinate the care they now provide in a fragmented way.

The White House and Congressional Democrats have stacked the deck for Mr. Obama’s health plan by making sure it is filibuster-proof. Despite their objections to such expedited procedures, Republicans continue working with Democrats in the Senate Finance Committee.

On Wednesday, the chairman of the panel, Senator Max Baucus, Democrat of Montana, and the senior Republican, Charles E. Grassley of Iowa, unveiled a set of detailed recommendations intended to slow the growth of Medicare, hold doctors and hospitals more accountable, and improve the care of patients with chronic illnesses.

Mr. Baucus said the changes in Medicare could be an engine driving a “transformation of the health care delivery system.”

After a six-hour meeting to discuss the proposals with members of both parties, Mr. Grassley said, “I did not find a lot of dissension.”

The two senators proposed a 5 percent bonus payment for office visits and other “primary care services” provided to Medicare patients by family doctors and internists. General surgeons in rural areas would receive a similar bonus, but Medicare payments to many other specialists would be reduced.

Lobbyists for doctors and nursing homes expressed concern about some of the proposals. But John C. Rother, policy director of AARP, the lobby for older Americans, said the package would be good for patients.

In setting forth detailed “policy options” and inviting public comment, Mr. Baucus and Mr. Grassley set a precedent for openness. Four other Congressional committees are developing equally ambitious proposals in secret.

These are some of the proposals advanced by Mr. Baucus and Mr. Grassley on Wednesday:

¶Medicare would increase payments to doctors who regularly exceed “national benchmarks” for the quality of care. Doctors who did not meet federal standards would be subject to financial penalties.

¶Medicare would pay bonuses to hospitals that provide superior care for heart attacks, heart failure, pneumonia and selected other conditions. The cost would be offset by cutting Medicare payments to other hospitals.

¶Doctors could receive extra payments if they hired nurses to manage follow-up care for Medicare patients who were discharged from the hospital after being treated for chronic conditions like diabetes, asthma, depression and coronary artery disease.

¶The government would set national standards for the appropriate use of CAT scans, magnetic resonance and other diagnostic imaging techniques. Medicare would cut payments to doctors who drive up costs by overuse of imaging services.

In addition, Medicare would make a single “bundled payment” for all the services provided to a hospital patient. The bundle would include payments for any nursing home care or home health services that a person received after leaving the hospital, an idea that made some providers uneasy.

“Under this policy, payments would be made to one entity, such as the hospital,” Mr. Baucus said. The proposal does not say how hospitals and nursing homes would divvy up the lump-sum payment.

Bruce A. Yarwood, president of the American Health Care Association, a trade group for nursing homes, said: “This proposal is a little bit scary. I don’t want to give hospitals full control of our Medicare payments.”

Val J. Halamandaris, president of the National Association for Home Care and Hospice, a trade group, said the payments “could be a windfall for hospitals that manipulate the system.”

The Senate proposal would also shine light on the financial ties between doctors and makers of prescription drugs and medical devices. Companies would have to disclose such payments and could be fined up to $150,000 for failing to do so.
Nursing homes would have to disclose the names of any shareholders or other investors who held an ownership interest in their properties. Wall Street investment companies and private equity firms have bought many nursing homes, often using complex corporate structures that obscure who controls the homes.