The Path to Payment Reform: We now have a Roadmap!

The HCQCC held their monthly meeting today. There were brief reports from the sub-committees starting with the Quality & Safety Committee, which gave a quick update on the Care Transitions Forum, the Expert Panel on Hospital Mortality, MOLST, and the Expert Panel on Care at the End of Life. All of the meeting materials are here. (UPDATE 11-13-09: The QCC has posted the full roadmap (pdf). All QCC materials are at mass.gov/healthcare.

There was also a quick report by the Brookings/Rand pilot on the Racial and Ethnic Health Care Equity Initiative. The slides and the presentation discussed a new way of collecting and analyzing data to address population-level racial and ethnic disparities. The Pilot program utilizes specific software analyses and indirect estimation to make predictions about the population. The conclusion of the pilot is that this method in making assessments is validated and should be broadly implemented.

The centerpiece of this meeting was again the Roadmap to Cost Containment. The group began with a continuation of detailed discussion of the specific initiatives (see our earlier blog here). First up was Health Resource Planning Capabilities. The Roadmap recommends that there is an annual assessment of health resource needs to inform an enhanced Determination of Need program looking at over and under supply of health care resources. This should enable DPH and DHCFP to monitor and evaluate our supply of health care resources. There is more information on the Roadmap discussion below the fold:

The second recommendation reviewed was Tort Reform. This recommendation requests that the Legislature look at existing medical liability reform legislation, gather all stakeholders together and create a system that benefits plaintiffs and defendants. Third up was consumer engagement. The two-pronged recommendation suggests a public education campaign about the health care system and also direct efforts focused on shared decision-making and consumer empowerment tools.

The next recommendation discussed was Promoting Good Health. This recommendation reminds us of the importance of public health initiatives like smoking cessation, reducing obesity, substance abuse and other chronic conditions. The Roadmap urges continued and increased funding of these initiatives where possible so that the health and financial benefits achieved thus far can continue. Number five on the list was supporting health care system re-design. The Roadmap recognizes that system redesign is a huge challenge and that one of the keys to success is encouraging open communications and sharing best practices and the experience of transition. EOHHS will convene large health care stakeholder meetings including large employers and state colleges and universities.

The next two recommendations were Health Information Technology and Administrative Simplification. Both of these recommendations endorsed the existing initiatives in their respective areas and requested that the QCC be updated on the progress of these same initiatives. The final ‘new’ recommendation discussed was on transparency. The transparency recommendation highlighted existing initiatives and also the new initiative unveiled by the Governor yesterday regarding small business health insurance (check out the Globe article here).

The QCC then went over a few upgrades to the recommendations they had discussed at the last meeting: pay for performance, payment reform, including Medicare in payment reform,

There was a lively discussion started by the Inspector General about whether the recommendation about Medicare would unfairly infringe on the Medicare beneficiaries due to the nature of ACOs. Secretary Bigby clarified that the recommendation is for the state to work with the Center for Innovation at CMS to discuss Medicare participation. Director Mitchell continued by emphasizing that the Special Commission on Payment Reform had explicit language about people who going outside of the ACO network. Both Secretary Bigby and Director Mitchell emphasized that this is a challenging task that will be dealt with by the Oversight Entity.

The Inspector General then said that he has ‘grave concerns about the Roadmap’. He offered up two amendments to counteract his fear that the provider consolidation contemplated under ACOs could have the principle effect of increasing costs due to anti-competitive market forces. The Inspector General recommended that prospective rate regulation be included in the Roadmap and that the Attorney General and the Division of Insurance be given broad statutory authority to review the anti-competitive elements in the design and formation of the ACO structure. The Council then discussed these amendments. Director Mitchell and Glen Shor discussed the rate regulation provisions in the Special Commission Report. The Oversight Entity was given intervention authority in the Special Commission Report, but there is no prospective rate regulation authority as contemplated by the Inspector General’s amendment. Also reviewed was the language currently used in the Roadmap, which highlights the need to utilizing rate setting if sufficient progress is not made, similar to the language used by the Special Commission. Some of the Council members argued that they felt an amendment like this would be premature for a number of reasons including the desire to avoid outcomes from a recommendation that were counter to the Roadmap’s goals. The first amendment was then seconded. A handful of Council members voted in favor of the amendment and the amendment failed. The second amendment was then taken up for a vote. This amendment also failed. They will continue to discuss these issues going forward in their work on cost containment.

The Council then continued its discussion of the Roadmap and presented a timeline of where the recommendations fall in a prospective timeline, which included several short-term strategies. Director Mitchell then recommended that they not shy away from saying rate regulation may be an interim step that would sunset if it were necessary to control costs dramatically. This was quickly discussed this to her satisfaction.

Secretary Bigby rounded out the discussion by emphasizing the compromise nature of the Roadmap and said that the ‘real winners were the people of Massachusetts’. The Council then approved the Roadmap, however the Inspector General declined to support the Roadmap due to the concerns he discussed above. Click here to read the current version of the Roadmap summary. We’ll post the full 94-pp document once it is available.