I’m hoping this isn’t the Underpants Gnomes method of payment reform (UPDATE)

“Blockbuster” announcement in the NEJM by Sylvia Burwell about plans to make Medicare reimbursement about quality instead of quantity. I call this pay-for-performance, and my skepticm is legion (also see here, herehere, here, here, and here). But I expect many in the media to swoon. I would love to be wrong, but I see no details yet to convince me otherwise.

But this money quote is suspect (emphasis mine):

As we work to build a health care system that delivers better care, that is smarter about how dollars are spent, and that makes people healthier, we are identifying metrics for managing and tracking our progress. A majority of Medicare fee-for-service payments already have a link to quality or value. Our goal is to have 85% of all Medicare fee-for-service payments tied to quality or value by 2016, and 90% by 2018. Perhaps even more important, our target is to have 30% of Medicare payments tied to quality or value through alternative payment models by the end of 2016, and 50% of payments by the end of 2018.

“Tied to” is vague. That could mean that a tiny portion of each payment is “tied to” quality. Or it could meant that a tiny portion of all DRG payments are “tied to” quality. I’m not sure this is the real overhaul of the payment system that some might seem to think it is. At this point, it feels all underpants gnomes.

But – again – I’d love to be wrong!


UPDATE: And if a majority of payments already have this wonderful link to quality or value, why are we still seeing so much waste?

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