AAFP, VISTA and economics

[Wayne Wilson]

The recent posting on the differential in economic incentives for various sub-parts of a large system has me thinking about the question John Gage raised about why is VISTA not more popular in the US?

We have the clinical effectiveness study published in favor of VISTA as one data point.
We now need to study the economic incentive model.

Let me explain. There are things about the VA economic structure I don't know, so all I can do at this stage is pose a test scenario which may or may not be the case:

Let's say that VA physicians work on a salary. Let's further say that an all electronic system requires more physician time spent on data input/patient. Overall, the system is more efficient though and can deliver a superior clinical experience. There is no dis-incentive or reason for the physician to not use the system, it can be evaluated solely on it's clinical experience.

Let's say that MetroHealth system works on a 60% fee for service/ 40% capitation model for physician re-imbursement.
Let's further suppose that downward price pressure (can anyone say Medicare/Medicaid cuts?) is reducing fee for service aggregate revenue. Then, as a physician, the economic incentive is to see more patients and that might mean spending less time/patient doing data input.

If this scenario is true (and if not at the VA, then perhaps in other central payor systems where physicians are on salary, which I believe exist in other parts of the world, Europe perhaps?) and the behavior is as I describe for both systems and people, then one could conclude that software developed in one incentive model will not work well in the other incentive model.

This could be a factor in explaining the differential uptake of VISTA. What do you all think?

If true, a large part of the argument for such systems is going to have be on matching the economic model of health care delivery.

p.s. I put the AAFP project in the title, because two of us discussed this incentive differential in that thread, and it could consequences for the success of that project's software!