Charlie Baker and I shared a podium today at the annual meeting of the Board of Advocates of the Jewish Family & Children's Service. JFCS provides a multitude of services to the community, and does so very well, and we both felt honored to be invited. We were led in a panel discussion by Sy Friedland, former CEO of JFCS, on the topic of "What's going to happen in health care, no matter what happens in Washington?" (You see Sy and Charlie in this photo.)
Before attempting a run for Governor in 2010, Charlie was CEO of Harvard Pilgrim Health Care, a highly respected health insurance company in the state. In previous lives, he served both as Secretary for Administration and Finance and as Secretary of Health and Human Service for the Commonwealth. As you might expect, he has lots of thoughtful things to say about the health care system.
I remember, during the campaign, that Charlie explained the major items of his health care platform to be increasing payments to primary care doctors and other cognitive specialists, with the purpose of giving them the chance to spend more time with patients and thereby avoiding as many referrals to higher paid specialists; pursuing broad-based transparency of cost and quality to offset unsupported reputations of certain hospital and physician groups that were thereby able to exercise undue market power; and to create coordinated medical management programs for the 120,000 dual eligible people in the state. These are folks who are "old enough for Medicare, but sick and poor enough for Medicaid."
As Charlie noted today, dual eligible people constitute 20% of Medicare subscribers, but account for 40% of Medicare spending. Likewise, they account for 15% of Medicaid enrollees, by 30% of Medicaid costs. Based on relatively small pilot programs in the state, covering about 15,000 to 20,000 people, coordinated management of these patients results in service delivery at 30% lower cost than the two uncoordinated programs. (My keen readers will quickly note that these contracts are annual fixed fee payments based on patient risk characteristics -- the one clear example that capitation can work in selected environments.)
Charlie's remarks were timely during the gubernatorial campaign, and they were more so today, in the Governor Deval Patrick has announced that he wants to create just such a program. Charlie graciously complimented the Governor on his intentions in this regard.
That still leaves his other two items to be implemented. Both remain excellent ideas.
Historically, insurers resisted disclosing actual contract rates paid to providers because they feared that providers who are paid less would clamor for higher rates while those who are paid more will not willingly reduce their rates. However, as tiered networks gain traction and, hopefully, critical mass, it should be easier for insurers to agree to disclosure their rates and tell lower paid providers that we pay some providers more because of their market power but we’ve also placed them in the non-preferred tier for most services and are doing everything we can to steer patients toward the most cost-effective high quality doctors and hospitals. At the same time, providers could tell smaller insurers that they get a smaller discount than the larger insurers because the larger insurers drive much higher volume to their facilities and practices. If I were a regulator, I think the public would be better served by full disclosure of actual contract reimbursement rates so everyone can see not only how provider rates compare to each other but how they compare to Medicare rates as well.
ReplyDeleteEven though Charlie Baker was not successful in his run for Governor, I hope he continues to push the healthcare cost and quality transparency issue hard.
While we're talking about unintended consequences, and lack of data to support efficacy of global payments, readmissions penalties, etc., there is really no data to support the popular idea you cite below:
ReplyDelete"increasing payments to primary care doctors and other cognitive specialists, with the purpose of giving them the chance to spend more time with patients and thereby avoiding as many referrals to higher paid specialists."
We really have no idea what would happen with these increased payments - all, some or none of the hoped-for results could pertain, or other unintended ones could surface.
So we really have no idea what we're doing in any of this.
nonlocal MD
Dear nonlocal,
ReplyDeleteWe do have some data, and that is from "concierge" doctors who take a limited number of patients (in return for charging an annual fee to the ones they take.) Of course, it is not rigorously collected or studied fully, but anecdotally, it appears to be in the right direction. That would be worth studying more fully.
We also know, talking to "regular" PCPs, that they feel it necessary to fill their days with many short appointments in order to make a living. They tell us that they end up being "triage" doctors, often just referring patients along to specialists when they know they could handle the conditions that are presented to them if they had more time.
Paul;
ReplyDeleteYour comment about concierge physicians is an interesting one and, I agree, worthy of formal study. I could hazard some theories that they have different incentives, but then I wouldn't have any data to support that either, so why bother?
As to PCPs' comments, I will ask a provocative question which I hope doesn't offend any (not my specialty):
has this triage been going on so long that it has affected practice and training of PCP's, such that they actually would not be able to handle some of these more complex conditions which they currently feel they have no time for?
nonlocal
I agree with that comment about PCPs. The system almost forces them into a high-traffic/fast-turnover schedule. It happens to proceduralists too, in a slightly different form.
ReplyDeleteThe concierge system may allow the primarys to use more of their cognitive abilities. And when they refer to a specialist, much of the workup will have been done.
Today, more specialists need extenders to sort through their new consults and help arrange the workups that would have been done by the PCPs in a past era.
Anon - actually, we do have evidence that more support for primary care can reduce hospitalizations and the cost of care overall - especially for very sick populations. The Atlantic Monthly has a story this month on just this issue...http://www.theatlantic.com/magazine/archive/2011/11/the-quiet-health-care-revolution/8667/
ReplyDeleteIt's worth a read.
Charlie (forgive the familiar, but it seems to be the norm these days (:);
ReplyDeleteI read your article and it is indeed impressive. However, to me this is entirely different than simply paying more to individual PCP's - it is a complete redesign of care with greatly enhanced coordination and rational use of care extenders. If THAT'S what you are advocating, then I enthusiastically agree - but just paying more to a private practice of 2-3 PCP's without anything else, I fear, may not have the same salutary effect.
nonlocal MD