The article is one of the latest to join a crowded and heated debate over the speed and extent to which hospitals, doctors and public and private payers should adopt alternatives to healthcare's fee-for-service (pay for volume) model, which is frequently criticized as an incentive for overuse and a contributor to rising U.S. healthcare spending.
Proponents of alternatives such as bundled or capitated payments contend that strong incentives are needed to change practice patterns. Others are more reticent, arguing that many doctors lack the expertise and capital needed to make the switch.
In an interview, Pines said he fears that safety net hospitals will rethink money-losing emergency departments under capitation contracts that pay a lump sum per patient. Hospitals and doctors lose money when patients' healthcare costs exceed the lump sum.
As policymakers debate how best to control health spending, Pines urged them to consider that such payments are “potentially disastrous.”
The cost to treat patients who visited the emergency room but were not admitted to the hospital climbed 33.5% to $82 billion in 2010 compared with 2006. Spending for patients who were hospitalized after an emergency room visit increased to $202.2 billion in 2010, or 17.3%.
Those numbers are not explained by a parallel rise in the number of patients. Emergency room visits grew 7.6% and the number of hospitalized emergency room patients increased 6.5%.
“We can't reduce these costs with a blunt instrument,” Pines said. “It has to be done in a way that is evidence-based and carefully monitored.”
The authors called for the development of emergency department quality and resource-use measures that could be tied to bonus payments in addition to the volume-based payments, which would give hospitals more incentive to maintain emergency care.
Pines authored the article with Dr. David Newman of the Mount Sinai Icahn School of Medicine, Dr. Randy Pilgrim of the Schumacher Group and Dr. Jeremiah Schuur of Brigham and Women's Hospital.
In addition to suggesting a hybrid payment model, they argue that changing physician behavior is essential to reduce less expensive tests and treatments.
They suggest that doctors would benefit from timely data that shows them how their use of diagnostic imaging and other services compares with that of their peers. “For providers, cost-consciousness needs to be a clearly articulated professional and organizational priority, and feedback on variations within groups is a first step in achieving that goal,” the authors wrote.
Dr. Christopher Moriates, an assistant clinical professor at the University of California San Francisco, said he agreed that greater awareness and sensitivity to cost within healthcare would require multiple strategies.
“Cost-conscious is really the bottom, the foundational requirement,” Moriates said. “You have to be conscious.”