Obamacare to launch new payment scheme

[Stellar]

More: Politico

Six years after President Obama’s health reforms became law, officials in his administration told POLITICO they are launching the largest-ever initiative to transform primary care in America, an effort to give doctors more flexibility and reward them for producing better results for their patients.

The experiment the administration will announce today, a program called Comprehensive Primary Care Plus, is intended to shake up the way 20,000 doctors and clinicians treat more than 25 million patients when it goes into effect in January 2017. In a sharp departure from the current “fee-for-service” system, which offers reimbursements per visit or procedure, providers who volunteer to participate will received fixed monthly fees for every patient and bonuses for meeting various quality goals. When their patients stay healthier and require less-expensive care, many primary care doctors will also share in the savings to Medicare, Medicaid or private insurers.

Most of the attention devoted to the Affordable Care Act has involved its coverage expansion for the uninsured and its new rules governing insurance, but its little-noticed changes to the actual delivery of care could be just as consequential in the long run. This new five-year primary care initiative would be its most ambitious delivery reform yet, designed to serve twice as many Americans as are now enrolled in the higher-profile Obamacare exchanges.

Health reformers of varied ideological stripes generally agree that the current fee-for-service system creates perverse incentives for providers, who get paid according to the quantity and volume of the treatments they provide rather than quality and value. Family doctors in particular complain that fee-for-service pressures turn their practices into assembly lines with mountains of paperwork at the end. The “cognitive medicine” that good primary care depends on—talking to patients, keeping in touch about what’s happening in their lives, figuring out their risk factors, nudging them in healthier directions—just isn’t as easy to bill as MRI’s or back surgeries.

The new initiative essentially offers participating practices a deal.

They will be required to give patients 24-hour access to care and information, and to meet various metrics for managing and co

[elleng]

1. Something like this?

'former Maryland Gov. Martin O’Malley, now suspending his presidential campaign, seemed to have the most reasonable health care platform to control rising costs and a record of accomplishments to back it up.

O’Malley’s platform was impressive in two ways. One, he successfully lowered costs in his state by changing the way hospitals are paid. And two, he hails from a state that has successfully run an all-payer system.

In a single-payer system, the government insures all citizens with a single plan, essentially abolishing private insurance. Such systems cut costs by increasing the negotiating leverage of the insurer.

Government-run health care such as Medicare and Medicaid currently pay much less for care because their patient populations are so large. This means they provide a large number of patients to providers who work with them.

A single-payer system simply insures everyone this way. However, raising the revenue for such a system requires a massive increase in tax revenue with consequent economic repercussions. The government must also decide which procedures to cover, leading to contentious political fights over newly developed but unproven treatments. This would stymie health care innovation by discouraging experimentation.

Finally, government-run health care tends to distribute service inefficiently. Canada’s single-payer system has infamously long wait times, and the U.S.’s Veterans Health Administration has received the same criticism.

Alternatively, an all-payer system preserves the present combination of public and private insurance plans, but regulates the maximum cost of each procedure. Maryland adopted this system in 1977.

From the time Maryland created the Health Services Cost Review Commission — the independent board tasked with negotiating rates with hospitals — in 1971 to 1995, Maryland’s cost per hospital admission went from 25 percent above the national average to 6 percent beneath it. This also limited cost shifting, wherein free emergency care given to the uninsured forces hospitals raises rates exorbitantly on insured customers.

During his tenure, O’Malley overhauled and updated Maryland’s all-payer system, requiring hospitals to cap cost increases at 3.58 percent — equal to the average per-capita economic growth of the state, according to Governing magazine. Under the plan, hospitals will also save Medicare approximately $330 million over five years starting in 2014.

Other countries have used this model with great success. In 2013, the U.S. health care expenditure to gross domestic product ratio­­ — the highest of 35 countries measured by the Organization for Economic Co-operation and Development — was about 5.5 percent higher than in Germany and 6 percent higher than in Japan — two countries that have all-payer systems.

Furthermore, under a payment scheme commonly referred to as global capitation, O’Malley created an incentivized structure to promote higher quality care.

To clarify, imagine a consumer at McDonald’s. The consumer decides how many hamburgers to buy based on the information about their hunger. Health care consumers don’t have the same information. Service providers, just as in a capitalistic enterprise like McDonald’s, have an incentive to supply more service. But unlike McDonald’s, service providers have a monopoly on information. U.S. health care expenditure is most likely high because doctors order more expensive procedures or more frequent hospitalizations under this fee-for-service incentive.

Under global capitation, rather than receive money for each hospital admission, hospitals receive a lump sum of money based on projected admittances. If the hospital is able to coordinate with the primary care physician to provide care outside of the hospital — where it is less expensive — then they keep admittances below the projection and retain the additional profit.

In Maryland, preventable hospitalizations dropped by 11.5 percent between 2011 and 2014. O’Malley’s goal in 2011 had been a 10-percent decrease by 2015. Moving from fee-for-service to global capitation contained costs, and, according to The New England Journal of Medicine, the system created an incentive for high-quality preventive care.

Despite the resounding success of Maryland’s health care model and the comparable efficiency of similar foreign systems, such reforms are earning little attention from the media. During the Democratic debate in Charleston, O’Malley forced himself into the discussion when health care was discussed. He only had the brief opportunity to vaguely reference his achievements.

It’s clear that O’Malley had the best health care record in practice. Unfortunately, due to his withdrawal from the presidential race, we’ll never get to see his ideas implemented on a nationwide scale.

Rather than focusing on Sanders’ grandiose promises and Clinton’s rhetorical claims about defending Obama’s legacy, perhaps we should’ve examined the progress of state-level experimentation in this election. Of course, that doesn’t offer the same level of political theatrics.'

http://dailyfreepress.com/2016/02/02/i/


http://www.democraticunderground.com/12815519

[jillan]

2. I hope whichever candidate is elected in the GE that they will find a cabinet position for O'M.

Personally I'd like to see him be in charge of converting to green energy.

He really impressed me & I never understood why he didn't get more recognition.
He was my 2nd choice.

[Stellar]

4. He was my first choice before he dropped out. NT.

[HDSam]

3. Unintended consequence?

"when their patients stay healthier and require less-expensive care, many primary care doctors will also share in the savings..."

Healthcare providers might cherry pick which patients they see, screening out those that are less healthy and requiring more expensive care in order to increase their share. I would hope this wouldn't happen, but I tend to distrust people when there is a profit motive.

[Yo_Mama]

5. This absolutely will happen. Esp. in group practices. n/t

[Chuuku Davis]

7. Surgeons in this area already

send obese diabetic smokers to the local teaching hospital

[spanone]

6. K&R...

[slipslidingaway]

8. This might work in certain areas, but I would like to hear from physician's who serve in inner ...

cities where patients are less likely to afford the follow up care and medications they need to achieve better results.

This reminds me of schools that receive less funding because disadvantaged students perform under expectations, why teach or practice medicine in such an environment? I would think the pool of physicians, or teachers, in certain, and very needy areas, would diminish.

Unless you can be at home with these patients, or students to further the analogy, and solve the daily problems they face I am not sure this will work for those most in need.