Guest post: Massachussetts leads the way!
Guest post by Michael Halasy Practicing Emergency Medicine PA, Health Policy Analyst, and Health Services Researcher
Massachussetts leads the way
We have talked about bundled payments here, and getting rid of the antiquated and inefficient fee for service model. It looks like Massachussetts is on board suggests The Washington Post.
Blue Cross is not alone. At Partners HealthCare, the famous Boston-based medical system that dominates health care here, Massachusetts General Hospital has been conducting a Medicare experiment in which nurses are assigned to coordinate care for about 2,500 older patients with multiple ailments. The experiment, which began five years ago, so far has reduced hospital re-admissions by one-fifth and cut medical spending by 7 percent.
They will be the first to implement integrated care organizations (really, a version of ACO’s) and a new bundled payment mechanism.
With 98% of the population insured, Massachussetts saw their costs soaring, at about 15% above the national average. The markets have already begun to respond, and some, like Partners, are already ahead of the curve.
At Partners HealthCare, the famous Boston-based medical system that dominates health care here, Massachusetts General Hospital has been conducting a Medicare experiment in which nurses are assigned to coordinate care for about 2,500 older patients with multiple ailments. The experiment, which began five years ago, so far has reduced hospital re-admissions by one-fifth and cut medical spending by 7 percent.
Massachussetts was bracing for this for some time. Last year, the insurance commissioner took on the health insurance companies for raising rates too rapidly. He rejected many of them outright. This was an important political maneuver, that really set the stage for the current willingness and cooperation of the insurers, providers, and hospitals.
As he says:
“We are preparing ourselves to grapple with a certain amount of constructive disruption in the industry,” Patrick said in a lengthy interview. “It’s a journey.”
Clayton Christensen would argue that it is JUST that disruption which is so sorely needed.
Simple bring back the HMO model where the primary care physician or physicians assistant is a gatekeeper, and specialists are purely consultants telling the primary care provider what to prescribe unless surgery is involved. In addition fully divorce the inpatient and outpatient roles to where hospitalists do all in hospital treatment. (In the process you can de-skill the primary care provider role why does it take 9 years post BS to fulfill the role?)
Massachusetts lead the way on 19 April 1775, let it lead the way in 2011 to better health care financing.
Gonna disagree a bit here. Healthcare Insurance is a symptom of rising healthcare costs led by $200 million dollar additions such as found in Syracuse to sell more services, procedures, and pharma as brought to us by specialists ratherthan primary healthcare. MA plan is to attack insurers, a symptom rather than get to the root cause.
No disagreement Run, this can only be a PART of systemic reform. But we need to incentivize service provision differently. This is one possibility.
By moving to bundled payments, and getting rid of fee for service, physicians/providers/hospitals can be incentivized to focus on quality and outcomes…to a degree at least.
My very limited experience of hospitalists (my 90 year old mother was the patient) has been quite negative. As far as I could tell, all he did was breeze by, saying something like “how are you today?” without waiting for an answer. He refused to give credence to anything I told him about my mother’s condition, whether currently or before admission, even though I am her health care proxy. He dismissed Mother’s hallucinations and delusions as “sundowning” even though she had never shown any signs of dementia or confusion prior to beginning a medication that had been prescribed for her condition before she was admitted. I had to talk to hospital administration to get him to call me (after numerous requests I had the nurse put in the chart, notes left for him, etc.).
Her own doctor would have known her condition both pre and post admission. Further, in her confused state, post-admission, she would have been more comfortable with a doctor she knew.
Hospitalists may be the wave of the future, but for me, they’re another reason I will avoid hospitals as long as I’m conscious and can say NO.
btw, when she was transferred to the “rehab” wing of the hospital, I was asked to sign authorization to continue that medication. I refused. They told me she needed to be titrated off it. I told them I would only sign if they would do that. Within 2 weeks of getting off that medication, Mother’s cognition was greatly improved, but it never returned to the level it had been at before that illness.
On the specialist model, you pay 50% of the bill if not recommeneded by the primary care physician and 0% if recommeneded.
Note that if you compare the education of a primary care physician today to one from 50 years ago its a lot more. Yes that is important for the hard cases but how many are hard? More and more as you move to evidence based care (defined standards of care that by defninition are not malpractice) medicine will be follow the checklist.
I guess one thing I see to reduce costs is to go to the model (once you have electronic medical records) where you see the next physician available. After all if you see the physician 30 mins a year as in my case, then he really only knows what his records say about you.
Maryland led the way on that topic. MA copied it
Well, HMO’s didn’t work very well when it came to specialist care. Some specialists actually talk to and treat their patients, monitor their progress, and do more than read CT scans. So, aren’t you asking people who put extra years into acquiring their knowledge to take great reductions in salary? Doesn’t seem fair, considering that we are introducing this concept in midcareer for a lot of doctors.
And, if we are going to bundle fees, perhaps capitation through some sort of contracts to provide care would work. So, the FP would have a contract to care for the patient and refer appropriately. Same for specialists. Treatment plan for each patient at a flat rate. Right now, I’m a terrific patient. Weight stays the same. Blood glucose levels stay the same. BP stays the same…etc. They were high but now controlled. If I have a recurrence of my autoimmune disorder, I could be in the hospital which any one of several acute life threatening disorders. Wouldn’t be ok to pay my rheumatologist what he’s worth to keep my AI disorder from killing me? NancyO