After a resounding Democratic Presidential election win, a terrible recession, and a bruising year of politics, it would be just like America that a crazy election result torpedoes the health care reform bill. It would be the first Republican Senator win in 43 years in Massachusetts, a state that’s bluer than blue, and the actual seat being elected on Tuesday hasn’t been won by a Republican since 1947!
Let’s play out what happens if we go back to a 59–41 Senate. The current Senate rules basically allow the minority to shut down proceedings. Harry Reid has in fact performed miracles to keep Lieberman, Nelson and some of the rest on board. Obama, Reid & Pelosi are now working the deal out with the unions and all the rest to make sure that what’s a pretty slim majority in the House will essentially accept the Senate bill—with some sop to the unions on the “Excise tax”. There are some other technicalities about the Exchange et al, but in the end we have a fair idea of what’s going to be the result.
How will the Senate bill impact health insurance companies and their customers?
Even better, how will it impact a not-for-profit health plan–one with a reputation for being a “good guy” that continually wins the country’s top awards for member services and with historic profits of less than 1% of premium? And, one that is operating in Massachusetts–a market that has already been through much of this?
I will suggest that, in combination, these are three intriguing questions.
That is why I thought that the Harvard Pilgrim’s CEO’s recent post on their website was important. It is short, direct, and to the point. And, from everything I know, it is bang-on.
Earlier this month, the Massachusetts General Hospital Cancer Center opened nominations for its annual gala honoring those who have stood out in the fight against cancer, the one hundred. Each year, one hundred people from all walks of life are honored by the Boston-based hospital for a variety of achievements. Doctors, nurses and researchers have been recognized for ground-breaking research and stellar patient care while those outside of the medical community, like Susan Zuker, were recognized for lobbying the state legislature for a vanity license plate that would raise money for cancer research, or the Boston-based “Cops for Kids with Cancer” program that supports families with children who have cancer. Last year, Elizabeth Edwards was also honored and was the keynote speaker of the gala. To nominate someone you think should be recognized for their outstanding fight against cancer, visit here
The Commonwealth of Massachusetts – along with a number of other states (including New Hampshire and Maine) and the federal government – is kicking around a number of ideas concerning payment reform. The argument goes something like this – since the current health care system, led by the gigantic Medicare program, pays primarily on a fee for service basis. This “do something” payment model encourages clinicians and hospitals to do “more” for patients than they might do otherwise, if they weren’t encouraged to “do something” to get paid. Add to that the fact that fee for service – again led by Medicare – pays more for new technology than it does for existing technology, and less for primary care, and you have the primary ingredients in the recipe that’s driven our system to be technologically driven, volume driven, fragmented and very expensive.
In Massachusetts, the group that’s working on payment reform seems to think the solution to this problem is to move everyone away from fee for service and into something that’s being called, “global budgets.” Put simply, global budgets are a new and improved form of capitation. Let me be clear on this one – I’m actually a big fan of both. I believed in capitation when I worked in state government, and I worked for a medical practice (Harvard Vanguard Medical Associates) before I came to Harvard Pilgrim that was built on global budgets.
And before I go any further, I would offer up the cover story in this month’s issue of Health Leaders Magazine – titled “Bundling By Decree” as a solid a representation of the pros and cons of this debate as it winds its way through the national discussion around health care and payment reform. This article is primarily about bundling payments around episodes of care, but the issues it raises – in both directions – apply in either context.
With that said, I wonder about whether or not global budgets, at least in the short term, are the answer to our health care cost and quality problems. For some provider organizations, global budgets work – but they work in large part because those particular clinicians believe in them, and want to practice in environments that are based on them (like Harvard Vanguard/Atrius HealthCare). But that represents a fairly small slice of the practicing clinician community – I’m guessing 10-15 percent. Maybe 20. It’s also not clear to me that this issue, above all else, drives our cost/quality problem, since many other countries that spend a lot less than we do on health care and have solid clinical results use fee for service payment systems too.
As far as I can tell, those other countries that spend less than us on health care do two things differently than we do. First, they spend less on each service than we do – sometimes a lot less. They also have robust primary care systems. This, in particular, is just the opposite of our approach. Our payment policies – and as a result, our medical education system – have been disinvesting in primary care for years.
In the short term, I’m not sure global budgets solve this disinvestment problem. First of all, it’s financial and operational whiplash for a system that’s been running on fee for service for years. That, all by itself, will take some getting used to. It’s also not clear that Medicare or Medicaid – which make up 50-60 of the payments to providers to begin with – would also adopt global budgets. If they don’t, having private sector payors using global budgets and the public sector payors using fee for service is just about the worst outcome I can think of for providers and their patients. The mixed messages these two payment models would send about what matters and what’s important would be virtually undecipherable.
This makes me wonder if our short term approach shouldn’t focus instead on changing the message all payors send under the current fee for service system to providers by improving the way we pay for primary care. No one thinks we can possibly deliver integrated, coordinated care if we don’t send some signals to the medical and medical education community that primary care matters. If a young medical student can make $250 an hour in primary care – or $1,000 an hour in dermatology – or $2-3,000 an hour in cardiology or orthopedics – how hard do you think it is to get that person into primary care? The answer is it’s wicked hard – and the declining number of students going into primary care coming out medical school for the past decade is proof positive of that. We used to be 50/50 primary care / specialty care. Now we’re 70/30, and some of the anecdotal information suggests that kids coming out of U.S. medical schools are now running 15/85 primary care/specialty care.
Think about it. No one disputes the fact that primary care has a key role to play in care management and care coordination – especially as the Baby Boomers get older. The state’s Payment Reform Commission says global budgets will take three to five years to implement – and expects that every doctor will be using an EMR as one of its requirments for success. Will this approach really grab today’s medical students and practicing clinicians and say – ”HEY! It’s time to invest in primary care!” In the short term, I think we’re more likely to get more capacity, faster, into primary care by boosting, on a relative basis, the fees paid to primary care providers by the private plans, Medicare and Medicaid.
Over time, maybe everybody gets to global budgets, but in the meantime, I think we need to do more to support primary care.
Massachusetts members of the Physicians for a National Health Program released a report today faulting the state’s experiment with health reform for failing to achieve universal coverage, being too expensive and draining funds away from safety-net providers.
The doctors’ punch line is that the reform has given private insurance companies more business and power without eliminating vast administrative waste. In fact, it says, the “Connector” in charge of administering the reform adds about 5 percent more in administrative expenses.
In summary, nothing less than single-payer national health reform will work, according to authors Drs. Rachel Nardin, David Himmelstein and Steffie Woolhandler, all professors at Harvard Medical School.
Advocates for health care reform have been keeping an eye on Massachusetts, hopeful that its new health reform law will serve as a pilot program for the nation.
I’m much less hopeful than I was two days ago.
Yesterday I attended the Massachusetts Medical Society’s Eighth Annual Leadership Forum where I was one of four speakers. This year, the Society (which owns The New England Journal of Medicine) focused on the cost of health care –with a special emphasis on funding universal coverage in Massachusetts. The new was not good. While the citizens of Massachusetts believe that everyone has a right to health care (when polled 92% say “yes”), no one wants to pay for universal coverage. When asked “if the only way to make sure that everyone can get the health care services they need is to have a substantial increase in taxes [should we do it] 55% said “no.”
One speaker at the forum recalled a man who explained why taxpayers shouldn’t have to pick up the bill: “The government should pay for it.” (He didn’t disclose who he thinks “the government” is. )Continue reading…