Health Care Payment Reform

Dr. Ron Paulus, chief technology and innovation officer at Geisinger Health, tells me that Geisinger is working on a model to encourage patients to comply with physicians’ orders–because patients tell physicians what orders they want to receive.

It seems to be working. Here’s what he says:

We know that many patients don’t actually follow the advice that they’re given by their physician, and our belief is that’s not because those consumers are stupid or mean-spirited. They’re actually very smart and they have a lot invested in their own health, obviously. We felt that there was a disconnect between what that consumer may be desiring and what it is that is being prescribed.

So we developed a mechanism, a touch screen-based questionnaire method, to elicit what kinds of interventions patients with coronary artery disease might be willing to undergo. Would they be more interested in drug therapy, or more interested in diets, or more interested in exercise?  And we also asked them questions, including, “I don’t want to do anything about my care.”

We think it’s very, very important to elucidate those preferences so that the doctor/patient interaction can focus on education, counseling, advice, and mutual engagement around what the right strategy is in caring for this particular patient’s disease.

…This whole area of activation and preference-eliciting is trying to make sure that the clinician and the clinical team and the consumer patient and his or her family or loved ones are all on the same page together. They all understand their mutual responsibilities, and they’re working toward a common outcome goal, where that consumer is engaged and willing and eager to follow that plan to achieve better health.

Dr. Bradley Perkins, chief strategy and innovation officer for the Centers for Disease Control and Prevention, tells me that Americans should change the words we use to describe our …well, I no longer want to use the term “health care” because that is too limiting. Read what he told me:

One of the things that we’ve been looking at very carefully is what is the current national dialogue  about health and health care? And it was clear that, for the most part, the dialogue has been about health care, and specifically about access to health care, uninsured people, quality of health care, and the cost of health care.

But the truth is that health is much broader than what happens in the doctor’s office. In fact, most of our health actually occurs outside of the doctor’s office, not as a result of health care. So, we’ve been working very hard to broaden the conversation in this country about what we need to become the healthiest nation in the world.

It’s going to require that all of us work together around notions that we’ve been talking about  as “health protection.” We feel like the word “prevention” is slightly narrow and sometimes gives the context that we’re only talking about what happens in the clinical world. “Health protection” might be a better concept or word to talk about a broader set of efforts around health promotion-how we encourage people to stay healthy;  around prevention -both clinical and community-level prevention; and preparedness-preparedness for emergency threats to our health, which we think are vital for national security.

When it comes to health care payment reform, Dr. Robert Galvin, director of global healthcare for General Electric, is keeping his eye on MedPAC. That means I have my eye on MedPAC because I think major employers will be a huge influence on how health care reform evolves.

Here’s what I heard in my recent interview with Dr. Galvin:

There’s a lot going on in payment reform, and if you look just in the private sector, we think there are now well over 200 pay-for-performance pilots going on. If you look in Medicare, at least seven or eight of their demonstration projects are on payment reform. So, it is a really active area that is, frankly, a bit chaotic at the moment.

I think that with this new administration, the focus is going to go more and more to Medicare, and if you look at Medicare and look at what they’re doing in payment reform, that really drives you right back to MedPAC, which is the agency that advises Congress, particularly on Medicare and particularly on payment reform.

And so I think a good place to start is to look at what MedPAC is suggesting, and it turns out that what MedPAC is suggesting is really pretty similar to what’s going on in the private sector. And I see several big ideas going on. One of the big ideas is that primary care doctors need to be paid more, and that the re-balancing, as it’s called, between specialty care that pays more for more interventions–and the more invasive the intervention, the more it gets paid—is something that people are really looking at. And they’re using the word “re-balancing.”

I think there’s a big push toward coordination of care, and I think you see that in two ways. One is in this concept of medical home, which is the idea that primary care doctors would be paid a new fee that doesn’t exist yet for coordinating care, if they meet the requirements of a medical home. And the other coordination idea going on has to do with this idea of blended payment, or instead of paying hospitals through Part A Medicare and doctors through Part B in a disconnected fashion, that you actually give a lump sum on A and B around particular diagnoses, and then let the doctors and hospitals figure out how to share that money. That’s another kind of coordination play.

The third big thrust I see is in this idea of not paying either for errors or unnecessary care. You see this in the never-events policy where Medicare has listed several events that they are not going to pay for, and some private insurers have followed. And you see it in an idea from MedPAC which says that preventable re-admissions–and they think actually up to 20 percent of people who are re-admitted on the Medicare program could have been avoided with better coordination of care, medication compliance, etc.—that those preventable re-admissions should be paid at a degree much less than the original DRG would tell you

So, those are three big trends – primary trend, coordinated care, and really looking at not paying for errors.