Years ago, I was reading a book about creativity and innovation.  One of the tips from this famed international expert was interesting. 

When you are struggling to solve a problem, he said, think about doing the exact opposite of what makes sense.

This would stimulate creative thinking and open up new options.

This is what sells books.

So I tried to think about how I could apply this advice:

• I could tell my kids they could stay up as late as they want on school nights.
• I could eat more ice cream and work out even less.
• I could tell my clients that I would pay them instead of them paying me.

This seemed to be wacky advice, but then I found sometimes where it was a helpful exercise.  This ‘think about what you would do, then think about doing just the opposite’ thing would occasionally open me up to a creative way of thinking.  I should have known.  The author of the book was British and wore really funky ties.  He had to be creative.

So I had one of those moments the other day.  I was having breakfast with a friend who is an executive at a health plan.  Yes, sometimes I do ‘opposition research.’  He works for a small, regional plan, not one of the gigantic payers.  Maybe that is why he is more creative and less dictatorial.  Or maybe he is just a good guy who works on the dark side.

Our conversation covered the waterfront on healthcare.  We talked about ObamaCare, the effect of the economy, and the fact that hospital systems were snatching up practices faster than an NBA player gets new tattoos. 

Finally, we got around to emerging reimbursement models, the part of the conversation that was most interesting to me.  I wanted to know what they were thinking on the other side of the wall about how they are going to pay physicians.

We talked about ACOs and bundled payments.  As I suspected, they want to move that direction, but are trying to figure it all out.  Is this just capitation with a new label, or something different? Either way, it is good for the consultants and the lawyers.

Then we talked about quality and pay for performance and he said the opposite of what I expected him to say and it was really insightful.

P4P schemas are all over the place.  Medicare and commercial payers are experimenting on the edges, trying to find a way to really tie some meaningful portion of reimbursement to some measure of quality.

They all generally run like this:  Identify a sub-group of patients, generally based on a disease state, and then require the physician to either do a certain thing, or document a certain thing, or maybe even prove a certain outcome.  If you do, we’ll give you some additional coins.  If not, well, we’ll keep our money.

Some practices, more often large ones than small ones, are trying to play.  After all, everyone needs all of those little coins they can get.

But that is where the problem comes in, and this guy actually got it.

‘We’ve got this backward.  We, the payers, are showing up with our pay for performance plans and telling the physicians what they have to do to qualify for these incentive payments.  But I have mine and the other payers have theirs.  They are all different and there is no way most practices can follow all of these different plans that each affect a small number of their patients.  So they just don’t participate.  It is not worth the hassle.’

Now here comes the man bites dog, do the opposite of what you think part.

‘Instead, what we need are physicians coming to us, the payers, saying, “OK, here is what we can do related to quality.  We are good at managing these types of patients, we have developed these protocols that we can and will follow, and we can provide you this proof of the quality of our care.  Now, let’s talk about how you are going to pay us for that.” That is what it will take to really change this thing.’

That 'think the opposite' thing is exactly right.

There are so many problems with the current system, where payers, be they government or commercial, define the reimbursement rules and then foist them on the providers.  It works this way because they are all really, really big and physicians are not.  But that does not make it the right way to skin this cat.

We end up with a system that is adversarial, in part because providers know there is a conflict between how they are paid and what everyone says they want, which is higher quality, lower cost care.

Only the providers, the deliverers of that care, can figure out how to get that right.

Across the table from me was a payer executive, the guy in charge of contracting, inviting physicians to flip this around and start the discussion with what they can actually do to improve care, what they can actually execute on a day to day basis.

The British guy would be nodding in agreement.

We don’t need more payer conceived pay for performance plans.  We need more doctor conceived ideas.  And physicians need to initiate the conversation.

But this gets us back to a common theme that we address often in this space.

This idea is hard to do for small practices operating independently.  They don’t have the resources to develop the plan, the information technology to enable it, or the management talent to operate it.

Yet one more reason that physicians must come together, be it in a legal integration or a virtual one.