Καταρχήν να συμφωνήσουμε στα δεδομένα. Πως αμοίβεται ο οικογενειακός ιατρός σήμερα εδώ στην Ελλάδα. Αν εργάζεται στο ΕΣΥ, το οποίο σα σύστημα φιλοδοξεί να παράσχει ΠΦΥ σε όλους τους πολίτες, αμοίβεται με συγκεκριμένο μισθό, ο οποίος καθορίζεται από αποφάσεις του υπ. Οικονομικών (off topic: παράλληλα, μπορεί να αναπτύξει και ένα "μαύρο" ταμείο, που μπορεί να είναι τα 2ευρα που πέφτουν για τη συνταγογράφηση ή άλλες παραδοδουλειές). Ο οικογενειακός ιατρός που παράσχει ιδιωτική ιατρική λαμβάνει αμοιβή ανά επίσκεψη και αν προχωρά σε εξειδικευμένες τεχνικές πληρώνεται και για αυτές. Το αν ο οικογενειακός ιατρός εργάζεται ή όχι, παραπέμπει στους ειδικούς με επιπτώσεις στο κόστος και στον ασθενή, συνταγογραφεί αυτό που οι μελέτες γράφουν, ελέγχει και επανελέγχει τη θεραπεία που έχει δώσει, ακολουθεί τα evidence-based δεδομένα, όλα αυτά δεν υπάρχουν πουθενά.
Προφανώς, το να εισάγεις ένα σύστημα P4P δεν είναι απλό. Στη συζήτηση που ανέφερα, η Katharine Treadway λέει πιο κάτω: I also — I think pay for performance with outcomes is very important, with the following caveat. And this is — I think there has to always be a little wiggle room, because I think all of us who have taken care of complex medical patients who, for example, have hemoglobin A1c’s in the nines, is not necessarily because you’re not trying. It is because there are social, psychosocial issues that lead this patient to “I’m not taking my 60 units of NPH this morning.”
Και επίσης λέει: I, just as an individual provider, thinking about how I would like to be paid, I would like to be — probably half of my salary to be a sort of, in exactly that model where I am paid for the number of patients I have, their age, and how complex they are. Just as a lump sum having nothing to do with whether I ever see them. One of the issues is we get paid for visits, and yet the job of primary care doctor is enormously taken up timewise by paperwork, completing records, doing prior authorizations, answering phone calls, talking to people, e-mailing people. So that I would say, since I’ve been in practice a long time and I have an elderly, sick population, that for every hour of face-to-face time, I have another hour, at least, of time that I spend that’s unreimbursed. So, if I’m there for 13 hours, I’m getting paid for about 6 of the hours I’m spending. So I do think that there should be a, you know, a substantial sort of lump of, “This is what you’re being paid to manage these people.”
Η συζήτηση συνεχίζει και όλοι συμφωνούν ότι αλλαγές στο σύστημα ΠΦΥ χρειάζονται. Και θα πρέπει να ξεκινήσουν αλλαγές δραστικές στην εκπαίδευση των νέων ιατρών. Ο Thomas Bodenheimer καταλήγει λέγοντας για το σύστημα αμοιβής: We have to reform payment, because right now what we are trying to do is a lot of practices are trying to change, sort of one practice at a time. Well, there are hundreds of thousands of primary care practices in this country. To change them one at a time is going to take forever. Real payment reform will really encourage and dictate that a lot of practices are going to change quickly. However, the “plus” is that the practices need assistance in becoming really good primary care practices. So part of the payment reform has to be that there have to be some kind of, I’d call them practice-improvement teams or practiceimprovement consultation to go to the practices and help them to make the changes they need. And there are people who are very good at doing that, but I think those practice-improvement teams should have patients on them, because otherwise we could go wrong.