From Mushrooms to Flowers

Art by Jill Bliss

“Money is not the African’s problem; it’s how to spend it.”

-Kimpianga Mahaniah (my father)

In my early days as a medical student and intern, I was struck by how concentrated the training was on my individual responsibility in that moment for a particular patient’s morbidity during a discrete event.  Population health was seen as beyond the scope of the 1:1 interaction. It was not an expectation that one would address the issues of the patient, the clinician, as well as discuss the 21 recommended screenings for the patient.  At the time, “team-based care” meant that everyone on the team was an extension of the physician who had the most status. Productivity was king; those leaders with the most responsibility for this had corner offices. Quality outcomes were seen as pressure from external stakeholders. QI teams were like mushrooms, kept in our institutions’ basement with little to no resources, brought out to the light only in preparation for audits.  Quality was an add-on, not a building block.  Although that state of being could be used to judge clinicians harshly, we were responding to the design of the fee-for-service (FFS) system.

For larger systems, from a financial perspective, primary care is essentially seen as a loss leader.  Primary practices are acquired to identify the patients necessary to generate revenue in the higher margin areas.  For community health centers, entirely concentrated in underserved communities and primary care (which meant unbelievably lower per encounter reimbursements as compared to private insurers), the current FFS system guarantees inequity.  Not only do FQHCs not provide the income generating procedures, but they see lower reimbursement per primary care encounter.  Since it takes more resources to care for patients of lower socioeconomic status, those who speak a language other than English at home, as well as those who live in chronically underfunded communities, the FFS systems make it difficult to increase support/services for those with the most needs, and to coordinate with sister agencies to address fundamental social determinants of health.  The real-life measures of well-being remained elusive as we strove to reach basic “quality” criteria.

The Value based care system being proposed would provide us with more financial resources, as well as flexibility to determine what services make the most sense, both as a system and at the individual level.

Under FFS, the challenge was squeezing enough out of a mismatched system to provide for the most desperately and inadequately reimbursed services. What services can you imagine providing, to positively impact the lived experience of the patient in a measurable way, decreasing the overall cost of care, and improving the quality of work for your team?