An article in today's Boston Globe about a state commission reviewing changes in the way doctors and hospitals are paid for delivery of care (from fee-for-service to a global payment) has prompted a huge number of comments on the newspaper's website. Here's mine:
Assuming this is the right thing to do, it would represent a shift in actuarial risk from insurance companies, which maintain cash reserves for such things, to doctors and hospitals, which do not. Does the Commission propose to make a change in accounting rules for insurance companies, so that their required revenues -- from the people and companies who pay for insurance -- are reduced to compensate for this shift?
Also, does the Commission have proposals to change the design of insurance products so that consumers know in advance that their choices might be diminished -- that they will be encouraged or directed to be cared for by physicians and hospitals within the orbit of the provider receiving the "global payment?"
The point is that, if this is the right way to go on payment for health care services, you need also to fix the insurance side of things to garner immediate savings for the public. You also need to let the public know what the new environment will be for their care so doctors and hospitals are not caught in the middle, the way it happened during the last experiment with managed care. If the Commission does half the job in its recommendations and leaves the rest to be fixed in the future, it will leave us will a lot of unintended consequences and will undermine the good that might otherwise come from a new payment scheme.
Beyond this, many of my colleagues at other hospitals have pointed out the importance of including mental health in this picture, if we are to go down this route. In the past, mental health services have often been "carved out", leading to underpayment and relegating these diseases to second class status. Dennis Keefe, CEO of Cambridge Health Alliance, states it elegantly:
The results of these systematic underpayment practices on mental health and substance abuse services is what we are seeing today in the Commonwealth; i.e. a growing and continuing shortage of bed capacity; bed capacity that greatly varies across regions and the State; poor access to these services within communities, particularly for the uninsured/underinsured; all of which results in the continued marginalization of services to this population when compared to individuals having other "medical" needs. This, to me, is particularly ironic, as I have often asked the question to groups and others, "who amongst you does not have a friend, colleague, or family member who has not had to cope with mental illness and/or an addiction"? I have never seen a hand go up......