Sunday, April 24, 2011

Time to test the global payment hypothesis

There are many interesting problems involved in implementing a capitated approach to health care payments, from the internal transfer payments among providers to questions about consumer choice. How can the Commonwealth decide that heading down this path is worth the strife if there is no objective analysis of the main proposal for changing that payment system?

Thus far, we make policy in a vacuum, only hearing from those organizations who have a vested interest in proving that this approach is the right one. In speeches and advertisements, they try to marginalize others who raise concerns.

It is time for Massachusetts to conduct a formal test of the global payment hypothesis.

To scrutinize the efficacy of this form of payment and get guidance for the future, let's have an objective third-party analyze the data to see what has been accomplished to date. I suggest the widely respected Massachusetts Health Quality Partners, but perhaps there is another other qualified group. Let's have an equally well respected group of people, perhaps headed by somebody like Brandeis' Stuart Altman, design the experiment and specify the data needs. Finally, let's have the whole analysis and data be totally open to review by anybody else who wants to look at it and conduct their own analysis. (It is not clear if current studies funded by advocacy groups, like this one, will be open to such review.)

What do we have to lose?


76 Degrees in San Diego said...

Perhaps a more urgent question in your state is "what system enables patients to have primary care?". There are no longer many primary care physicians who can remain economically viable on discounted fee for service reimbursements as independent practitioners. Associating together for the purpose of negotiating FFS contracts is legally "anticompetitive" in most scenarios.

Anonymous said...

The answer to 8:58pm question is "nurses and social workers". In much of Massachusetts, few primary practices are stand alone, and it has been this case for years. Nor is the human capital pipeline viable for patients to have an MD provide asthma counseling, depression screens, and blood pressure scripts. Primary care will be increasingly delivered by staff, and coordinated by physicians proximately, and physician groups distally in risk analysis.

Questions about quality of that care are the same as they should be about quality delivered by MDs. No doubt the costs will be calculated to fractions of cents, but moving forward we should be demanding the analysis of quality and data that Paul describes. Healthcare too often moves forward like businesses do: let's try this and watch the P&L numbers. This huge turn in course would best serve governments, hospitals, providers and patients alike if it were conducted with aggressive and broad measurement of current state, quality and quantity of intervention, and follow-up. Some of these data are being collected, but none that I know is tranparent.

Holly said...

Why do I feel like you are batting your head against a wall. The devil is in the details and if we do not understand what we are doing we will be a repeat of California. Economics and risk is the same regardless of the intent or the state. Keep writing.

Paul said...

Statistics are great, they will show you what ever you want. It is very difficult to get a true unbiased review for anything.

Unknown said...

We make use of midlevels in our practice ostensibly to enable same day access. We make use of support structures within our IPA for our managed care patients. But, people do want to see their primary care physicians in spite of all the ancillary services/impediments that are offered to them.

Humans want relationships.

B.Belcher said...

If midlevel practitioners are being used as "ancillary" support staff - or at least being portrayed as such to patients -- there lies a problem. Many patients are primarily seen by PAs and NPs. The connection patients seek is not with their "physician", it is merely with a health care provider (doc, PA, or NP) that will listen and care for them.

The incentives of capitation are contradictory to what we expect from primary care providers. We want our PCPs to care for the chronically ill, yet capitation says to only pay a set amount. Why would PCPs want to keep these sick patients in house, why not refer away the sickest? There is some promise to capitation, but reimbursement needs to be outcome based, not treatment based.