Fee-for-service

Fee-for-service (FFS) is a payment model where services are unbundled and paid for separately. In health care, it gives an incentive for physicians to provide more treatments because payment is dependent on the quantity of care, rather than quality of care. Similarly, when patients are shielded from paying (cost-sharing) by health insurance coverage, they are incentivized to welcome any medical service that might do some good. FFS is the dominant physician payment method in the United States,^[1] it raises costs, discourages the efficiencies of integrated care, and a variety of reform efforts have been attempted, recommended, or initiated to reduce its influence (such as moving towards bundled payments and capitation). In capitation, physicians are discouraged from performing procedures, including necessary ones, because they are not paid anything extra for performing them. In the Japanese health care system, FFS is mixed with a nationwide price setting mechanism (all-payer rate setting) to control costs.^[2]

Health care

In the health insurance and the health care industries, FFS occurs when doctors and other health care providers receive a fee for each service such as an office visit, test, procedure, or other health care service.^[3] Payments are issued retrospectively, after the services are provided.^[4] FFS is inflationary, raising health care costs.^[4] It creates a potential financial conflict of interest with patients, as it incentivizes overutilization^[5]—treatments with either an inappropriately excessive volume or cost.^[6] FFS does not incentivize physicians to withhold services.^[7] When bills are paid under FFS by a third party, patients (along with doctors) have no incentive to consider the cost of treatment.^[8] Patients can welcome services under third-party payers, because "when people are insulated from the cost of a desirable product or service, they use more".^[9] Evidence suggests primary care physicians who are paid under a FFS model tend to treat patients with more procedures than those paid under capitation or a salary.^[10] FFS incentivizes primary care physicians to invest in radiology clinics and perform physician self-referral in order to generate income.^[11]

Private-practice physicians and small group practices are particularly vulnerable to declining reimbursement for patient services by government and third-party payers. Rising regulatory demands, such as the purchase and implementation of costly EHR systems, and increasing vigilance by government agencies tasked with identifying and recouping Medicare fraud and abuse, have bloated overhead and cut into revenue.

While most practices have succumbed to the need to see more patients and increase FFS procedures to maintain revenue, rising numbers of physicians are looking to alternate practice models as a better solution. In addition to value-based reimbursement models, such as pay-for-performance programs and accountable care organizations, there is a resurgence of interest in concierge and direct-pay practice models.^[12] When patients have greater access to their physicians and physicians have more time to spend with patients, utilization of services such as imaging and testing declines.

FFS is a barrier to coordinated care, or integrated care—exemplified by the Mayo Clinic—because it rewards individual clinicians for performing separate treatments.^[13][14] FFS also does not pay providers to pay attention to the most costly patients,^[15] ones that could benefit from interventions such as phone calls that can make some hospital stays and 911 calls unnecessary.^[15][16] In the United States, FFS is familiar to doctors and patients, as it is the main payment method.^[1] Executives regret the changes to managed care, believing it, FFS, turned "industrious, productivity-oriented physicians into complacent, salaried employees."^[1][7] General practitioners have less autonomy after switching from a FFS model to integrated care.^[17] Patients, when moved off of a FFS model, may have their choices of physicians restricted, as was done in the Netherlands in their attempt to move towards coordinated care.^[17]

When physicians cannot bill for a service, it serves as a disincentive to perform that service if other billable options exist. Electronic referral, when a specialist evaluates medical data (such as laboratory tests or photos) to diagnose a patient instead of seeing the patient in person, would often improve health care quality and lower costs. However, "in the private fee-for-service context, the loss of specialist income is a powerful barrier to e-referral, a barrier that might be overcome if health plans compensated specialists for the time spent handling e-referrals".^[18]

In Canada, the proportion of services billed under FFS over the period of 1990 to 2010 shifted substantially.^[19] Less care was paid out for patients under the age of 55 while for those over 65, payment for diagnostic services was sharply increased.^[19]

Reform

Moving away from FFS towards pay for performance introduces quality and efficiency incentives, instead of solely rewarding quantity.^[14] In addition to the Mayo Clinic, other health care systems that serve as coordinated/integrated care alternatives to the FFS model include the central Pennsylvania Geisinger Health System (where the physicians, residents and fellows are paid a salary with the potential for bonuses depending upon patient performance), Utah's Intermountain Healthcare, the Cleveland Clinic, and Kaiser Permanente.^[11] Coordinated care can produce cost savings of ~50% when compared to FFS programs, but long term savings for payers may not exceed 40%.^[17] A goal of accountable care organizations (ACOs), part of the 2010 U.S. Patient Protection and Affordable Care Act (PPACA), is to move from FFS to integrated care.^[20] ACOs, however, fit largely into a FFS framework, and do not abandon the model entirely.^[21] This approach suggests policymakers are attempting to avoid provoking public outcry, as happened with managed care in the 1990s by giving providers incentives to give less care.^[21] The PPACA aims to first move Medicare away from FFS, then other payers.^[22] A Swiss study showed physicians wanted significant pay raises to leave FFS for an integrated care model, while patients wanted lower premiums before they would choose one, results that hint at difficulties for PPACA aims.^[17]

In China—where FFS resulted in costly, inefficient, and poor quality health care with a degeneration in medical ethics—reforms have been initiated to realign health care provider incentives.^[4] Experimentation with new payment models is undergoing and recommendations include a strengthening of medical ethics, alterations to provider's profit motives, and, in cases where hospitals retain their profit motive, segregating physicians from the goal of profit.^[4]

In the U.S., a 1990s move from FFS to pure capitation provoked a backlash from patients and health care providers.^[14] Pure capitation pays only a set fee per patient, regardless of sickness, giving physicians an incentive to avoid the most costly patients.^[23] In order to avoid the pitfalls of FFS and pure capitation, models of episode-of-care payment and comprehensive care payment have been proposed.^[23] In 2009, the U.S. state of Massachusetts (with the then highest health care costs in the country) had a group of ten health care experts who worked under legislative mandate to come up with a plan to tackle costs (the Massachusetts Payment Reform Commission); they unanimously concluded the FFS model must be done away with.^[15] Their plan included a move away from FFS to a global payment system that had similarities to a capitated system.^[15] No U.S. state, up to 2009, had attempted to do away with FFS.^[15] The Medicare Payment Advisory Commission (MedPAC), in their mid-2011 report to Congress, called for a mechanism so that Medicare beneficiaries would have disincentives to undergo discretionary care, but not needed care.^[24]

Examples

• Medicare in the U.S. is a FFS program.^[25]
• In an area not related to health services, the United States Patent and Trademark Office operates on a FFS model.^[26]

Real estate

In real estate, the fee-for-service model of paying a broker provides an alternative to paying commission. In the fee-for service pricing model, a broker may charge for showing trips or other services.^[27]

See also

• Bundled payment
• Preferred provider organization
• Health maintenance organization

References