Scientific Plausibility And Reimbursement

In the ongoing quest for affordable care, our health care system is in dire need of solutions. If we don't find a way to save some money soon, the system as a whole will implode. Health care will become cost-prohibitive for many - if it isn't already.

We've got to start somewhere. So let's begin with a basic foundational premise: reimbursement based on scientific plausibility.

Did you hear the pin drop in the room? That's because there would be a lot of practitioners that would angrily resist the concept.

Why so? It would demand clinician accountability.

There is a belief throughout health care that a clinician should be entitled to payment for a procedure because they performed it. But just because you perform a procedure - scientifically plausible or otherwise - doesn't mean you are entitled for reimbursement. Third party payers should not be obligated to provide payment for the health care equivalent of snake oil. And there are plenty of variations on this theme currently in existence in health care, all clamoring for their share of the health care reimbursement pie.

I can hear it now ...

"Why should I have to prove what I do?"

It is unethical to provide care when you know it doesn't provide benefit. There is no better way to begin to assess benefit than to hold interventions to the scrutiny of the scientific method. If the approach doesn't have scientific plausibility, then not only should it not be used, but it certainly shouldn't be reimbursed.

I would bet that you would see a significant shift in health care. Basing reimbursement on scientific plausibility would promote a move towards the use of evidence-based strategies. Those that do so would thrive in the marketplace - those that don't, wouldn't (and probably shouldn't anyways).

Here's a thought, third party payers - starting right now, don't pay for scientifically implausible forms of care any longer. If the assessment or treatment doesn't stand up to the rigors of the scientific method at it's most basic level, the level of "could it really take place physiologically" or "is it even plausible in the world of science", then it surely isn't deserving of reimbursement. Simple.

That doesn't mean that a patient can't choose whatever treatment they want. Go right ahead, have whatever type of care you so desire. However, don't expect your insurance company to reimburse for it. As a matter of fact, expect to reimburse the clinician directly out of your own pocket. This would maintain patient choice, but it would also lend the notion that third party reimbursement will and should be science-based to enforce standards of critical thinking and reasoning.

The road to more affordable care could start with payment based on scientific plausibility. Let the insurance companies pay for evidence-based strategies that have a foundation in science. Embrace them and reimburse for them. Voila! Cost savings - and no rocket science necessary.

All it requires are some guts. So, insurance companies, do you have the wherewithal to do something like this? And clinicians, are you ready to base your practice on science and not pseudo-science?

Photo credits: Jeremy Weate

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