Visiting the Cleveland Clinic this week, President Obama held up that well-known hospital as a model for the rest of the country. But for most of the nation's nearly 6,000 hospitals, copying the Cleveland Clinic would be like asking the Durham Bulls, a minor league team, to copy the New York Yankees.
A more accessible example is a hospital that sits a bit more than a home-run blast from the Baseball Hall of Fame here. Called Bassett Healthcare, this modest hospital of 180 beds delivers high-quality care at low costs in the face of federal reimbursement policies that discourage many of its best practices.
Changing those policies is crucial to the success of health care reform, economists say — something Mr. Obama said that he would do. "Our proposals would change incentives so that doctors and nurses finally are free to give patients the best care, not just the most expensive care," the president said Thursday in Ohio.
But almost nothing in proposed legislation that has so far emerged in Congress would encourage the creation of similar hospitals.
Bassett looks like a small liberal arts college, with ivy-covered fieldstone buildings connected by a warren of passageways. But what really sets it apart is the way the system pays its 260 doctors.
Doctors in the United States are usually paid fees for each service they provide. The more procedures and tests they order, the more money they pocket. There is widespread agreement among health policy analysts that many of these procedures are unnecessary, raising costs in ways that often do nothing to improve patient health.
By contrast, Bassett — like the Cleveland Clinic and a small number of other health systems in this country — pays salaries to all of its doctors. No matter how many tests or procedures are performed, they take home the same amount of money. Medical costs at Bassett are lower than those at 90 percent of the hospitals in New York, while the quality of care ranks among the top 10 percent in the nation, surveys show.
Dr. William F. Streck, the longtime president of Bassett, said the hospital paid salaries that were competitive with the money earned in a fee-for-service setting. Some fee-dependent physicians, though, either by working hard or by providing excessive treatments, can make more, an ability doctors trade associations have long defended.
"Everyone knows that the Bassett model is the right model," said Senator Charles E. Schumer, a New York Democrat involved in negotiations over health care legislation. "The question is, How do you get from here to there?"
It is a question that has plagued lawmakers and medical experts for nearly a century. As early as 1910, Abraham Flexner wrote a landmark report that argued teaching hospitals should be staffed only with salaried doctors. In 1970, the Carnegie Commission released a report calling for drastic improvements in rural health care, and highlighted Bassett as a model.
Many doctors who work at Bassett believe deeply in its mission. Bassett has opened 13 clinics in schools around the region. The clinics lose money, but Bassett is considering opening 14 more.
"I was in private practice for years in New Mexico," said Dr. Philip A. Heavner, the chief of pediatrics at Bassett, "and there was no interest in doing anything like this because people thought it would take volume away from their practices."
Dr. Randall Zuckerman, an attending surgeon at the Hospital of St. Raphael in New Haven, left Bassett a year ago because his wife wanted their four children to grow up closer to family. Since many of his patients see fee-dependent doctors, Dr. Zuckerman said in an interview, their care is more disjointed than was common at Bassett.
"They get a lot of different consultations, some necessary and some not," he said. "They are always missing parts of their medical records because the information is coming from multiple private offices."
