Martha Bebinger, on leave from WBUR to participate in the Nieman fellowship at Harvard University, has written a solid, hopeful summary of the Massachusetts payment reform process for the journal Health Affairs. Bebinger’s article, Mission Not Yet Accomplished? Massachusetts Contemplates Major Moves On Cost Containment, is an editor’s choice selection and is thus currently available for free on the Health Affairs site.
And Rep. Jason Lewis (D-Winchester) has published an op-ed lauding payment changes as the next phase for Massachusetts reform.
Rep. Lewis clearly lays out the advantages of global payments over the current system:
Under the current fee-for-service system, doctors, hospitals and other healthcare providers are compensated for each test and procedure they perform. This creates incentives to provide more tests and procedures, and more expensive services. Doctors and hospitals tend to be divided into silos, which makes it difficult to coordinate care. Primary and preventive care are under-compensated and thus underutilized. In sum, we have a system today that rewards “inputs” rather than what really matters, the health and well-being of patients.
Conversely, a system of global payments would reward doctors and hospitals for keeping patients well. Groups of coordinated providers would receive a payment designed to cover all of a person’s needed care over a period of time, adjusted for health status and other risk factors. They would work closely together to manage all of the care that a patient requires. Patients would receive more preventive care, and better overall management of their health needs.
Bebinger’s article affirms Lewis’ point. She describes in detail the success Mount Auburn Hospital and its physician network, the Mount Auburn Cambridge Independent Physician Association (MACIPA). They have been receiving global payments from insurers for years, and making it work:
The main reason that global payments work, says [MACIPA president Barbara] Spivak, is that the system has been motivated to invest money up front in care management and coordination. Taking aim at the costly problem of hospital readmissions, for example, Mount Auburn now employs case managers who conduct home visits with patients who’ve recently been discharged from the hospital. The case managers do home safety evaluations, checking for something as simple as whether there are slip-proof mats under rugs to prevent falls—a common and particularly dangerous injury for seniors. When a patient goes into a hospital for a hip fracture, Dr. Spivak notes, the cost can run $40,000–$50,000; by contrast, preventing the fracture costs about $1,000, she says.
The shift to global payments has also produced a very different medical culture within the system—starting with primary care physicians, who are now at the front lines of managing patients’ care in a way that is “completely upside down from the way a lot of other places are structured,” says Mount Auburn president and CEO Clough. In most health systems, specialists are in charge on the physician side, and the hospital runs its own show. “It takes a lot of different thinking on the part of the hospital to be at the mercy of a primary care network” and let doctors largely control risk-based contracts, Clough says. …
Patients also get the benefits of having close contact with their personal physician while still being part of a system. They get letters signed by their primary care doctors reminding them that it’s time for a colonoscopy or a mammogram; few if any probably have any idea that these letters are generated en masse by the IPA through electronic review of patient records. When patients do see their physicians, they also get an earful about the importance of preventive measures. During recent office visits, Dr. Haft pushed one patient to try one more method to quitting smoking, and another to get a colonoscopy.
Bebinger explains in detail the political obstacles involved in getting fundamental change implemented in Massachusetts, and cites cautions from major providers and a comparison to the Big Dig. She quotes consumer groups (er.. me, and GBIO’s Rev. Hamilton), saying that consumer protections need to be upfront. Overall, both pieces provide a good preview of the payment reform debate to come.
– Brian Rosman
