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Say we get some sausage–then what?

sausage (sô´sǐj)
n. A highly seasoned minced meat usually stuffed in casings of prepared
animal intestine.

MPainter

Congress is obviously in the thick of the sausage making. The August recess is pending. Bills may or may not be moving. The legislative process, especially at this point, is not particularly pretty or, to be honest, as thoughtful as we all might hope. It is the process, though, right? There was essentially no way around something like this intestine stuffing, especially in an effort to fix health care–such a large sector of the American economy. And in spite of the messy work and depending on the day, the observer and the poll, it nevertheless seems likely that something will come out of the kitchen, right? It is also probably safe to say, though, that any reform law is not going to be the panacea–the ultimate health and health care fix. Instead, if a law indeed passes, it's clear that we're going to spend the next five, 10, 15 years adjusting, backtracking, redesigning and working toward better care. In other words, the implementation is going to matter, and it's going to matter a lot. On July 30 in Washington, D.C. at the Hart Senate Office Building, the RWJF-funded High-Value Health Care Project led by Mark McClellan of the Engelberg Center at Brookings hosted a panel discussion focused on just that–the implementation. Specifically, Mark, Carolyn Clancy of AHRQ, John Tooker of the American College of Physicians, Steve Findlay of the Consumers Union and Jim Chase of Minnesota Community Measurement talked to a large Capitol Hill audience about what it will take to make health care deliver sustainable high value. 

The panelists agreed that the drive toward high-value health care was indeed a critical part of successful reform. However, they also noted that we don't yet have all ingredients to drop easily into legislation. They acknowledged that performance measurement and public reporting of that information, help for doctors and nurses to improve once they understand the need to improve, and an informed and active public are all keys to high-value care–and thus to successful health care reform. They also acknowledged that the health reform implementation issues are dependent on national as well as regional or local action. And they noted that reforms that might be coming to our states, cities and towns are going to depend heavily on people's ability to transform their local health systems and health care marketplaces. And remember Massachusetts with its state-coverage innovation and the lowering of its number of uninsured? Well, the value question–and structuring payment to reward value, rather than lots and lots of expensive volume–is taking on a special urgency there. It's not hard to see that same experience playing out across the country after national reform. Again, value is key–and payment that rewards value is a necessary component of the value equation. And, yes, the payment question found its way into the discussion as well. But the panel also noted that we don't yet know what kinds of payment might support the necessary delivery system changes. We don't know what kinds of payment will truly drive value. Capitation? Fee for service? Pay for performance? Shared savings? Global payments? Episode-based payments? Some mix of all of these? We just don't know yet. And we probably can't know until we actually try some new fixes. So, the Hill conversation pretty clearly highlighted that value is critical to successful, sustainable reform–but also that we don't have all the ingredients yet. There's going to be a lot of learning, studying and piloting in the implementation. And a big part of that learning while implementing must happen regionally and locally. That realization and those challenges could be pretty sobering–except for a couple of important things. First, there's this important convergence of opinion that these national health care leaders noted–that reform must focus on the value of care. So we're pointed in the right direction it seems. Second, there are those existing unfolding local and regional reform efforts like RWJF's Aligning Forces communities and the AHRQ chartered value exchanges that are working to develop many of these missing ingredients of high value. We're probably very fortunate that there are communities out there already ahead of the curve–laying the groundwork in ways that might just make reform ultimately successful.

Michael W. Painter, J.D., M.D., is a physician, attorney,
health care policy advocate, and 2003-2004 Robert Wood Johnson Health
Policy Fellow. He is currently senior program officer and a senior member of the
RWJF Quality/Equality Team.

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StevenMD as HELLGIMMICKArletha Anderson, M.D.The Mind Relaxer Recent comment authors
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Steven
Guest

I don’t think there’s a greater health risk right now like the h1n1 swine flu virus, the government isn’t telling us everything about this pandemic. It will kill thousands more this fall/winter.

MD as HELL
Guest
MD as HELL

Wake up, people. This is not about healthcare. They will not invite you to the table because your solution involves dislocating everyone who is presently well fed by the system, including the patient who helps not himself.
Sucking more money out of the private sector and using the resulting power to the detriment of “the rich” in the name of “spreading the wealth” is what this is all about. In fact eliminating the private sector in healthcare is the only political goal. thereby delaying the wreck of the Good Ship Medicare.

GIMMICK
Guest
GIMMICK

“Capitation? Fee for service? Pay for performance? Shared savings? Global payments? Episode-based payments? Some mix of all of these? We just don’t know yet. And we probably can’t know until we actually try some new fixes.”
ARE YOU KIDDING ME. IT IS NOT THAT COMPLICATED.
CUT THE GIMMICKS AND PAY THE DOCTORS TO PROVIDE COST EFFECTIVE CARE. PAY THEM WELL TO SAVE COSTS OF UPWARDS OF ONE QUARTER MILLION BUCKS PER PHYSICIAN.
MEDICAL CARE QUALITY CAN NOT BE LEGISLATED.
THE YEARS OF GIMMICKS AND CONSTRAINTS HAVE CAUSED THE MESS.
STOP GIMMICKS NOW.
LISTEN TO DR. ANDERSON.

Arletha Anderson, M.D.
Guest

We have been begging the Obama administration & our new head of HHSSecretary Sebelius to invite us to the discussion table to lower health care costs. We are still waiting to be contacted. We know you are busy but come on, what will it take to get someone with real world, everyday experience taking care of thousands of the sickest, oldest, and most costly patients to the table? Dr Anderson geriatric specialist is well known for her physician home care program over the past 10 years seeing real patients that reduces costs by 75% and increases quality of care. See… Read more »

The Mind Relaxer
Guest

Just hoping that the sausage will be cooked right and not be toasted.

The EHR Guy
Guest

I like the lobster and ceaser salad post much more than this one.
Sausage isn’t too healthy for you.
Single-payer is the way, so please lets not delay.
Thanks,
The EHR Guy

Robin, Chevy Chase MD
Guest
Robin, Chevy Chase MD

Yes. We will need to make a second and a third sausage but I also agree with the first commenter that we have good models out there and we need to help these models grow.
One issue that I would like to see more discussion on is the influence of ownership. How can we legislatively arrange it that increased profits in a company are achieved through good health outcomes? Perhaps payer-provider partnerships offer the closest match to an organization where profits will come from good health outcomes. There are a few examples of these. They deserve a closer look.

Hal Horvath
Guest

“But the panel also noted that we don’t yet know what kinds of payment might support the necessary delivery system changes. We don’t know what kinds of payment will truly drive value. Capitation? Fee for service? Pay for performance? Shared savings? Global payments? Episode-based payments? Some mix of all of these? We just don’t know yet.” That answer is pay-for-outcome, which is easier to structure to handle complexities then you’d guess. But for the most conservative — “we probably can’t know until we actually try some new fixes” — types, then sure, use an already-demonstrated system: so-called “accountable care”, such… Read more »