Medicine and Psychiatry, University of Hawai'i at Manoa John A Burns School of Medicine, Honolulu, Hawaii, USA.
IHPS, UCSF, Berkeley, California, USA.
Int J Soc Determinants Health Health Serv. 2023 Oct;53(4):543-547. doi: 10.1177/27551938231176358. Epub 2023 May 24.
Current forms of payment of independent physicians in U.S. health care may incentivize more care (fee-for-service) or less care (capitation), be inequitable across specialties (resource-based relative value scale [RBRVS]), and distract from clinical care (value-based payments [VBP]). Alternative systems should be considered as part of health care financing reform. We propose a "Fee-for-Time" approach that would pay independent physicians using an hourly rate based on years of necessary training applied to time for service delivery and documentation. RBRVS overvalues procedures and undervalues cognitive services. VBP shifts insurance risk onto physicians, introducing incentives to game performance metrics and to avoid potentially expensive patients. The administrative requirements of current payment methods introduce large administrative costs and undermine physician motivation and morale. We describe a Fee-for-Time payment scenario. A combination of single-payer financing and payment of independent physicians using the Fee-for-Time proposal would be simpler, more objective, incentive-neutral, fairer, less easily gamed, and less expensive to administer than any system with physician payment based on fee-for-service using RBRVS and VBP.
美国医疗保健中独立医生的现行支付方式可能会激励更多的医疗服务（按服务收费）或更少的医疗服务（人头付费），在专业之间不公平（基于资源的相对价值量表 [RBRVS]），并分散临床护理的注意力（基于价值的支付 [VBP]）。作为医疗保健融资改革的一部分，应考虑替代系统。我们提出了一种“按时间收费”的方法，该方法将根据必要的培训年限和服务交付及文件记录时间，按小时费率向独立医生支付费用。RBRVS 高估了程序，低估了认知服务。VBP 将保险风险转移给医生，激励他们在绩效指标上玩游戏，并避免潜在昂贵的患者。现行支付方式的管理要求引入了大量的管理成本，破坏了医生的积极性和士气。我们描述了一种按时间收费的支付方案。与任何基于 RBRVS 和 VBP 的按服务收费的医生支付系统相比，单一支付者融资和使用按时间收费提案向独立医生支付的组合方式更简单、更客观、激励中立、更公平、更不容易被操纵且管理成本更低。
