Under strong prodding from Co-Chair Leslie Kirwan to act with
urgency, members of the state Payment Reform Commission last week
started leaning to global payments as its preferred, long-term
solution to controlling health care costs.
Kirwan's position offered little comfort to those who want to
proceed carefully and slowly with alternative payment models. The
state's big budget deficit is clearly weighing heavily on her mind,
and this is not helped by the Group Insurance Commission's
projected $60 million deficit for this fiscal year (as reported by
its executive director, Dolores Mitchell.) This suggests that any
new system will have to work with existing funds, not new
funds.
At Friday's meeting, commission consultant Michael Bailit put
three payment models on the table: fee for service, episodes of
care systems, and global budget. Fee for service was quickly
labeled as the wrong solution. Episode of care systems were
dismissed as unrealistic because the infrastructure needed won't be
available soon enough.
So the conversation moved quickly to global payments. Most of
the discussion focused on how to get there. According to commission
research, 57% of health care payments in Massachusetts go to the
seven largest systems: Partners, Beth Israel Deaconess, Children's
Hospital, Caritas Christi, University of Massachusetts, Baycare
(Springfield) and Atrius (the parent company of several large
physician practices in Eastern Massachusetts). These systems
already have significant financial, legal and technical
infrastructure in place, which is a prerequisite for succeeding in
any global or capitated system.
But what about 43% of payments that don't go to these systems?
Commission members, especially MMS Vice President Alice Coombs, MD,
cautioned against taking actions that could put the small,
unaffiliated practices out of business. Coombs and others also said
that significant physician input is critical to any payment model
transition. This would be especially true for a global budgeting
system, which requires a level of management expertise that only
some hospitals and the largest practice groups have at their
disposal.
What would be needed to facilitate a transition? Commission
members mentioned a number of things:
- Common performance measures across all payers (this attracted
the most agreement)
- Strong IT infrastructure, with interoperability among IT
systems
- Significant technical support
- Good analytical tools
- Transparent data reports
Importantly, commission members discussed incentives more in
terms of carrots rather than sticks - providing incentives for
adopting rather than penalties for failure to do so.
Nothing was decided definitively, but the sentiment is clearly for
something decisive and "bold." The commission meets next on
April 10, from 11 a.m. to 2 p.m.
