NationalJournal Live Policy Summit: Health Reform Innovation: New Concepts in Care Delivery
Maria Harris Tildon: Senior Vice President, Public Policy & Community Affairs, CareFirst BlueCross BlueShield
Neera Tanden: President, Center for American Progress, former senior advisor for health reform at the Department of Health and Human Services
Bruce Bagley: Interim President and CEO, TransforMED
Chet Burrell: President and CEO, CareFirst BlueCross BlueShield
Marci Nielsen: CEO, Patient-Centered Primary Care Collaborative (PCPCC)
Kavita Patel: Fellow and Managing Director of Delivery System Reform and Clinical Transformation,
Engelberg Center for Health Care Reform, The Brookings Institution
Purpose: When President Barack Obama spoke about the Affordable Care Act, he described that one of his goals was “bending the cost curve downward.” By focusing on delivery system reform, these goals may be achievable; it may ease financial pressure on Medicare, and make healthcare reform more likely to succeed.
Information, problems, and proposed solutions:
Accountable Care Organizations. Accountable Care Organizations (ACOs) are home medical programs that link insurance payments to healthcare providers to the quality of care they deliver. Typically, ACOs care for a group of patients and aim to reduce costs for a population of patients. Providers receive more provider reimbursement based on the quality of care and the total reductions in the total cost of care for the population of patients. BlueShield of California has over 40,000 patients in their ACO program and has saved more than $15 million since its inception. There is a concern that there will be too much concentrated power with ACOs.
Patient-Centered Medical Home (PCMH). PCMHs are a type of ACO. The concept of a PCMH is to embrace the relationship of patient and physician and make it, as the name suggests, patient-centered. Typically there is a team of health care professionals who are assigned to a certain group of patients. The health care professionals focus on the entire well-being of a patient, instead of focusing on the specific ailment. The panelists held up PCMHs as a model that works in the real world. Tanden stated that for every $1 spent on PCMHs, yields $1.50. Since PCMHs are responsible for the overall well-being, they keep all of the medical data and all of their patients and have to be able to access it at all times. The primary care physicians involved in PCMHs , when referring to specialists have to choose when to refer to a specialist, who to refer to, and why. CareFirst found that the physicians would try to find the specialists’ quality of care and the cost of the specialists. People are concerned that physicians may choose lower cost specialists who may provide less quality with their care. CareFirst has not seen that much of it happening. They argue that their physicians are shopping wisely.
Bundled payments. Commonly referred to as episode payment, it is the reimbursement of health care providers on the basis of expected costs for clinically-defined episodes of care. It is the middle ground between fee-for-service reimbursement and capitation. The panelists would like to see guidelines established the accepted costs for each episode and then nuance the payments based on the sickness/ailment. Out of the various suggestions for delivery system reform, the Congressional Budget Office (CBO) has the most optimism for bundled payments. The elimination of fee for service for everyone is probably not realistic. Getting Medicare patients off of fee for service has been encouraged. The problem seen with bundled payment at this time, is the lack of transparency from health care providers in terms of cost for each episode. Another concern is that doctors could monopolize prices, without releasing the information about how much it should really cost.
The Center for Medicare & Medicaid Innovation (CMMI). CMMI supports the development and testing of innovative health care payment and service delivery models. CMMI can stand to be more aggressive with its use of ACOs and bundled payments. CMMI did issue a grant to bring more Medicare patients into the PCMH model. The panelists believe that while CMMI is critical to health care reform, we may not be able to keep it at the national level and might have to find more reforms locally and at the state level.
Workforce problems/solutions. There has been estimates, that because of the people who are going to be insured for the first time that we will need 50,000-80,000 more primary care physicians. The panelists would like to see appropriate care taken care of at the appropriate place. They argue for more teamwork between professionals and patients, with an understanding that patients are only patients when they are actually in the health care office setting and have a real life outside of having their ailments. The panelists suggest that we should have a real discussion about skill-task realignment. Additional training given to various health care professionals may reduce the demand for primary care physicians. Another suggestion is that by focusing on the overall well-being of the patients, we might also reduce the demand of primary care physicians.
Healthcare costs. Healthcare costs have fallen and there is much debate over what is the chief cause of this decrease in costs. Some argue that it’s some of the reforms that have been rolled out and others say that it is because of the great recession. Most agree that it is a combination of the two.
CareFirst. CareFirst has a PCMH program that serves about 1.2 million people. There are about 420 panels, primarily made up of 8-10 (no more than 15) Primary Care Physicians who serve them. CareFirst is focused on primary care being done in an effective and responsible way. It Is team-based rather than hero-based. Each panel is responsible for the aggregate costs and well-being of each patient. CareFirst requires the panels to have a global budget and will cover the cost of every visit made by every patient. Each visit is debited to the panel. The panels are encouraged to not schedule unnecessary services because of this. The Primary Care Physician Panels are encouraged to focus on the well-being of the patients because they get added pay (certain percentage of the money saved) if they come in under budget. The physicians also receive extra for coming up with health care plans for their patients to help them stay healthy. They found that 94% of the costs were to specialists.
Overall health care reform. The panelists believe that we are close to an overall behavioral change between patients and physicians within the next 3-5 years. There are arguments that we should give states and localities more flexibility to achieve similar outcomes. All of the panelists agree that there is not one universal model that is going to be perfect, but rather we should focus on a combination of reforms.