Commission co-chairs Leslie Kirwan and Sarah Iselin opened the
meeting noting the significance of what the commission was about to
endorse. They briefly discussed the context of the commission's
work, namely the unsustainable rise in health care costs. They also
asserted, "the status quo is not an option." They were also the
first to note that the vote was the first of many steps to payment
reform.
Consultant Michael Bailit, whose firm did the bulk of the
commission's research and fact-finding, spent the next 30 minutes
outlining the work the commission did, and why it believed that
global payments provide the best opportunity to moderate costs
while also promoting high-quality care. Among his comments:
- The chief entity under which providers would organize to accept
global payments, accountable care organizations (ACOs), could be
wither "real" or "virtual." That is, they can have a formal
corporate structure, or operate as more loosely governed entities.
Bailit said the commission's definition of ACOs is "broader" and
"more flexible" than described by Dartmouth's Eliot Fisher, who has
popularized the concept.
- Advanced medical homes will be an important part of the new
payment model, but by themselves are not sufficient to achieve the
commission's cost-efficiency goals. Bailit said, however, that the
success of ACOs is predicated on a robust and primary care
infrastructure. He said primary care practices will have to
redesign their operations, and should be compensated sufficiently
to operate as medical homes.
- Good risk-adjustment is critical to the success of this model.
Bailit said there will be two kinds of risk in this system:
insurance risk, and performance risk. Insurance risk will
be carried by the health plans, and will address issues outside the
control of providers. Providers will be carrying performance
risk, which covers areas of care over which they do have
control, such as clinical results. He said this distinction between
these types of risk is "essential" to the success of this model,
and is one of main differences between global payments and
capitation as it was practiced in the 1990s.
- "Global payments is no a symptom for capitation," he said. The
key difference between global payments and capitation include: a
careful and thoughtful transition period; robust monitoring of
results; performance measures linked to patient-centered care;
improved risk-adjustment tools; improved health IT tools. "There is
much more data available to us today than even 10 years ago," he
said.
After Bailit's presentation, each commission member was given
about five minutes to comment. With apologies for the lack of
completeness that follows, here is a summary of what they had to
say.
Sen. Richard Moore, co-chair of the Legislature
Committee on Health Care Financing: He would have
preferred more detail in the report about the recommendations will
be implemented. "This is just the beginning; there is much more to
be done." He also wondered how this recommendation would be
coordinated with any federal reform legislation. Later in comments
to reporters, Moore said he hoped to start holding hearings on ways
to implement the report later this year.
Rep. Harriet Stanley, co-chair of the
Legislature Committee on Health Care Financing: She noted that this
is the first step in the process, not the last.
Alice Coombs, MD, MMS President-Elect:
Physicians want to be part of the effort to develop a better
system. They will with other stakeholders to ensure that there is
sufficient support for providers to succeed under global
payments.
Lynn Nicholas, Mass. Hospital Association: She
pointed out several "significant" issues that hospitals will be
watching closely:
- Whether ACOs will in fact be responsible only for the risk that
is under their control;
- Whether it's possible to give patients the right to move among
ACOs and meet the goal of moderating costs;
- Administrative simplification, malpractice reform, end of life
care, consumer alignment, primary care development, supporting
teaching in hospitals, and others, must be addressed. they are
"critical" to the success of the program, not just "complementary
strategies" as expressed in the report.
- The significant initial cost of realignment practice structures
"should not be underestimated."
Deborah Enos, representing the Mass.
Association of Health Plans: There needs to be flexibility in the
composition of ACOs. The design of benefit packages must align more
closely with the goals of integrated global payment systems.
Investments in health IT need to be shared by all.
Nancy Kane, Harvard School of Public Health:
She doesn't think that federal reform will "blow us out of the
water," but the added federal subsidies that Massachusetts has been
enjoying under the Medicaid waivers will diminish.
Andrew Dreyfus, Blue Cross Blue Shield of
Massachusetts: During the drafting of the first health reform
law, sponsors deliberately decided to focus on expanding
access and deferred decisions on cost and quality until the
future."The future is now," he said. He also said that if the
sponsors of the original bill had tried to addressed every detail
in the law, nearly a half million people still wouldn't have health
insurance today. Fee-for-service incentives for volume and
complexity don't serve us well today. Global payments can put
physicians and patients back in the center of the health care
system.
Leslie Kirwan, state Secretary of
Administration and Finance: She praised the MMS' work in collecting
detailed feedback and insight from physicians throughout the state.
"There's always going to be learning in this," and success will lie
in responding to developments as the system is implemented.
The commission then unanimously voted to accept the report.
