There is considerable discussion regarding aligning incentives to lower the total cost of care, and even more specifically, on the importance of diagnostic testing, the value it might bring, its accuracy, and the shared decision-making when ordering tests. Therefore, aligning incentives around appropriate diagnostic testing is critical to both diagnostic excellence and affordability of healthcare.
Additionally, an important piece of data to recognize is 30% of autopsy reports reveal a significant undiagnosed disease. Whether or not these were the cause of death is not the question; instead, it’s merely the fact that we have a low accuracy rate of present disease states in people. Furthermore, diagnostic errors are more common than medication errors. Of course, considering a differential diagnosis list and using the appropriate tools is complicated and complex; however, it’s essential to continue to strive for improvement in this important aspect of the continuum of care.
One factor potentially contributing to these issues is the lack of incentive alignment concerning making a diagnosis, having a diagnosis be accurate, and the how we come to such a diagnosis. Currently, payment is rendered regardless of these critical factors in the current fee-for-service environment. Moreover, whether one’s discovery is proven wrong or uncovers other incidental situations, one is still paid to continue searching for a diagnosis on the original problem and the recent finding. And treatments are handled similarly.
We must evaluate how to align incentives with diagnostic testing and accuracy. What if we were positively incentivized to use evidence-based diagnostic testing only? What if our payments were tied to an outcome measure of how accurate are our work ups? Presently, in value-based models, we are incentivized not to deliver unnecessary care since that cost goes to our total cost of care, yet what defines needed care? Sure, missing a diagnosis might be costly in the long run. However, there is cost in the process itself that might weigh on the minds of the clinicians. Consequently, the value-based payment models may lead to avoidance, and not incent diagnostic correctness or timeliness.
One possible solution is to incentivize using decision support tools and adhering to their guidelines in a stepwise fashion. Applying our medical society guidelines and a corresponding coding modifier would create such a process. Hence, we need to pivot our thinking concerning payment models that are stratified based on what we do and the outcomes we obtain. Should one be paid more for accuracy and the speed of diagnosis? Yes, there is a cognitive component of diagnostic decision-making, yet much of what we do would be better served with decision support tools. Let us innovate in what we do for those we serve and the payment models of how we provide our diagnostic care.