What is P-for-P? A new government project like Public Pays Private Partnerships? Maybe, a formalized policy titled Piss on Poor People? No, it is a new style of public hospital management, Pay-for-Performance, and it has been on trial during the past two years, funded by the province’s Health Innovation Fund.
It’s another step in the Americanization of Health Care brought to us by the British Columbia Illiberal Party. As a result, we move one step closer to a result predicted years ago by a doctor friend. He said:
The time will come when financial decisions will override life-saving medical choices. Government willingness to fund health care will fall short of the public’s need for services.
The principle will be more broadly at work in September when BC Illiberals present the real provincial budget to replace their pre-election sham.
The provincial health authority claims P-for-P rewards improved performance and uses financial incentives to drive change. This concept moves away from block funding to a reimbursement model in which payments are provided per procedure or for specific outcomes. For example, if an emergency department patient who requires admission receives a bed elsewhere within 10 hours, emergency is paid $600. A lower acuity patient sent home from emergency within two hours results in a payment of $100.
Under the traditional public system, funding is provided and patients are moved according to medical needs. If an unstable patient in emergency requires extended monitoring and intensive care, they are kept until medically appropriate ward care is arranged. Under P-for-P, emergency personnel have an incentive to move the patient elsewhere, even if tests and evaluations are incomplete and the destination ward lacks adequate resources. In fact, hospital personnel -Progress Chasers – are assigned to the task of ensuring “decongestion” bonuses.
Similarly, payment for sending a low acuity patient home within two hours may discourage best practices. Sometimes, passive observation is medically appropriate or a lab test or x-ray is needed. Time constraints work against those choices. Also, will contact with a new arrival be postponed to delay start of the two hour treatment window?
The underlying direction to emergency departments is, “Do less, send the problems home or at least move patients somewhere less visible.” Emergency departments are high profile with congested wait lines open to public view, 24 hours a day. They give confirmations of inadequate service availability. If a patient awaiting treatment is instead housed on a stretcher in the hallway of a convalescent ward, that is not a public event. Reality doesn’t change, the perception of it changes.
While applauding the trial program, Vancouver Coastal Health admits that block health funding is likely to be replaced by payments for medical procedures, based on schedules prepared by funding bureaucrats. Government caps its contribution, regardless of a procedure’s cost. That may result in Health Insurance BC deciding that it will pay $x for a knee replacement. If in fact the procedure costs $y, a patient will pay the excess.
This is the system now used for pharmaceuticals. Health Insurance BC determines that it will recognize an amount assigned to the lowest cost generic form of a drug, or of one similar, instead of the medication prescribed. If the scheduled price is exceeded or the non-generic drug is required, the patient privately pays the excess. Extended medical insurers follow these directives, even where a prescribed drug has no generic equivalents. A reasonably similar generic will do. The aim is to cap the cost, not to deliver the best medical outcome.
Medical necessity ought to be the motivating factor in determining a patient’s experience in hospital. Programs such as P-for-P may result in minor cost reductions but that is realized through reduction in service quality. Inevitably, reduced health service will be paid for with patient lives.