Moving Away From Fee-for-Service

This antiquated model is the culprit behind exponential health-care cost growth.

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A doctor stands outside the Supreme Court during legal arguments over the Affordable Care Act in Washington. / Reuters

National health care spending reached $2.6 trillion in 2010, a total of 17.6 percent of the United States' gross domestic product (GDP). Though health care cost growth dipped slightly in recent years (largely due to reduced consumption of services during the economic downturn), rapid cost growth is expected to continue in the foreseeable future. By 2020, health care will consume 19.8 percent GDP. At the same time, many Americans are not receiving recommended care and nearly half of all Americans suffer from chronic disease such as diabetes or hypertension.

Many experts point to the outdated fee-for-service (FFS) model of paying for care as a culprit in out of control health care cost growth. In a FFS model, payers reimburse for all services, regardless of their impact on patient health. Little or no countervailing pressure to discourage the delivery of unnecessary services exists in this system. While most patients are shielded from the direct cost of care by insurance, the fear of lawsuits ("defensive medicine") encourages doctors to order any and all tests.

Moving away from fee-for-service requires realigning the care delivery and payment incentives in the health care system. We must reimburse based on the quality and utility of care provided, not just the sheer volume of services. This idea--paying for "value over volume" or "paying for performance"--is now a common refrain in the world of health policy. Some experts even go so far as to say that too much care can be detrimental to health, such as unnecessary or redundant medical imaging scans that expose patients to excessive radiation.

ORIGINS

During the years prior to WWII, fee-for-service originated as "traditional indemnity" health insurance--you get a service, submit your claim, and your insurer covers your incurred expenses. What we now think of as "managed care" emerged around the same time, as prepaid insurance plans. In a prepaid plan, beneficiaries pay a set premium in return for care from a defined network of providers.

Due to wage controls during WWII, employers began offering insurance benefits as a way to attract employees--a trend which continues to this day. Indeed, a number of key trends in health care emerged after WWII: medical and scientific technology advanced dramatically, and more people enrolled in health insurance coverage. As health care costs grew in subsequent years, managed care, which encourages greater control over the utilization of health resources and services, also increased in the 1970s and 1980s.

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Unfortunately, managed care ultimately failed to control health care costs, and increasing restrictions on care led to a patient- and provider-driven political backlash in the late 1980s and 1990s. While managed care plans grappled with increasing cost pressures, providers also saw their margins narrowing, and physicians were left with more work and less autonomy. Less restrictive models of health care payment, like the more open-network Preferred Provider Organization (PPO), replaced more restrictive closed-network health management organization (HMO) reimbursement models.

Presented by

Julie Barnes is the director of health policy at the Bipartisan Policy Center (BPC). More

Prior to her role at BPC, Barnes served as deputy director and later as acting director of the New America Foundation Health Policy Program. Barnes also served as a litigator and regulatory counsel in the Health Care Practice Group of Crowell & Moring's Washington, D.C. office. In addition to litigating compensation and benefit disputes, her practice included advice and counsel to managed care organizations, self-funded employers, behavioral health organizations, disease management companies, and health-related trade associations on state, and federal regulatory and litigation matters.

Barnes is the author of several policy papers, the editor-in-chief of a legal textbook published by the Bureau of National Affairs entitled Managed Care Litigation, and is a frequent speaker for the American Health Lawyers Association and the Governance Institute. She received her law degree from American University's Washington College of Law and undergraduate degree from the University of Iowa. She is a member of the Maryland and District of Columbia Bars.

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