MMS Testimony Relative to Single Payor Legislation

Before the Health Care Financing Committee

  • H.1033/S.604, an Act Establishing a Public Health Insurance Option
  • H.1026/S.579, An Establishing Medicare for All in Massachusetts
  • H.965/S.647, An to Ensure Effective Health Care Cost Control

In the Health Care Financing Committee’s consideration of the above referenced legislation, the MMS wishes to share the following policies from our House of Delegates. We hope these adopted policies will help inform legislators of the views of physicians on a broad range of relevant approaches and issues relating to access to health care, payment reform and quality assurance.

The following policies have been adopted, and in some cases renewed under our sunsetting rules, over the past decade or more. The MMS is proud of its role in supporting universal access to care and in working to effectively implement this goal through our advocacy in a manner that is consistent with our policies.
 
The Massachusetts Medical Society adopts the following Principles for Health Care Reform:

  1. Physician leadership. Physician leadership is seen as essential for the implementation of new payment reform models. Strong leadership from primary care and specialty care physicians in both the administrative structure of accountable care organizations (ACOs) and other payment reform models, as well as in policy development, cost containment and clinical decision-making processes, is key.
  2. One size will not fit all. One single payment model will not be successful in all types of practice settings. Many physician groups will have a great deal of difficulty making a transition due to their geographic location, patient mix, specialty, technical and organizational readiness, and other factors.
  3. Deliberate and careful efforts must be undertaken to guard against the risk of unintended consequences in any introduction of a new payment system.
  4. Fee-for-service payments have a role. While a global payment model could encourage collaboration among providers, care coordination, and a more holistic approach to a patient's care, fee-for-service payments should be a component of any payment system.
  5. Infrastructure support. Sufficient resources for a comprehensive health information technology infrastructure and hiring an appropriate team of physician assistants, nurse practitioners, and other relevant staff are essential across all payment reform models.
  6. Proper risk adjustment. In order to take on a bundled, global payment or other related payment models, funding must be adequate, and adequate risk adjustment for patient panel sickness, socioeconomic status, and other factors is needed. Current risk adjustment tools have limitations, and payers must include physician input as tools evolve and provide enough flexibility regarding resources in order to ensure responsible approaches are implemented. In addition, ACOs and like entities must have the infrastructure in place and individuals with the skills to understand and manage risk.
  7. Transparency. There must be transparency across all aspects of administrative, legal, measurement, and payment policies across payers regarding ACO structures and new payment models. There must also be transparency in the financing of physicians across specialties. Trust is a necessary ingredient of a successful ACO or other payment reform model. The negotiations between specialists, primary care physicians, and payers will be a determining factor in establishing this trust.
  8. Proper measurements and good data. Comprehensive and actionable data from payers regarding the true risks of patients is key to any payment reform model. Without meaningful, comprehensive data, it becomes impractical to take on risk. Nationally accepted, reliable, and validated clinical measures must be used to both measure quality performance and efficiency and evaluate patient experience. Data must be accurate, timely, and made available to physicians for both trending and the ability to implement quality improvement and cost effective care. The ability to correct inaccurate data is also important.
  9. Patient expectations. Patient expectations need to be realigned to support the more realistic understanding of benefits and risks of tests and clinical services or procedures when considering new payment reform models. Physicians and payers must work together to provide a public health educational campaign, with an opportunity for patients to provide input as appropriate and engage in relevant processes.
  10. Patient incentives. Patient accountability coupled with physician accountability will be an effective element for success with payment reform. An important aspect of benefit design by payers is to exclude cost sharing for preventive care and other selected services.
  11. Benefit design. Benefit designs should be fluid and innovative. Any contemplation of regulation and legislation with regard to benefit design should balance mandating minimum benefits, administrative simplification, with sufficient freedom to create positive transparent incentives for both patients and physicians to maximize quality and value.
  12. Professional liability reform. Defensive medicine is not in the patient’s best interest and increases the cost of healthcare. In an environment where physicians have the incentive to do less, but patients request more, physicians view litigation as an inevitable outcome unless there is effective professional liability reform.
  13. Antitrust reform. As large provider entities, ACO definitions and behavior may collide with anti-trust laws. The state legislature may be the adjudicator of antitrust issues. Accountable care organizations and other relevant payment reform models should be adequately protected from existing antitrust, gain-sharing, and similar laws that currently restrict the ability of providers to coordinate care and collaborate on payment models.
  14. Administrative simplification. Physicians and others who participate in new payment models, including ACOs, should work with payers to reduce administrative processes and complexities and related burdens that interfere with delivering care. Primary care physicians should be protected from undue administrative burdens or should be appropriately compensated for it.
  15. The incentives to transition. In order to transition to a new model, incentives must be predominantly positive.
  16. Planning must be flexible. Accommodations must be made to take into account the highly variable readiness of practices to move to a new system.
  17. Primary care physician. All patients should be encouraged to have a primary care physician with whom they can build a trusted relationship and from whom they can receive care coordination.
  18. Patient access. Health care reform must enable patient choice in access to physicians, hospitals and other services while recognizing economic realities.

Fee-for-Service

The MMS recognizes that fee-for-service and private practice medicine can be efficient, ethical, and high quality medical care, with a long tradition of patient-centered care and cost-effective care which keeps patients at the center of treatment decisions.

The MMS, when advocating for system reform, enthusiastically advocates for preserving the viability of a private practice option, for the benefit of patients and our members.

The Massachusetts Medical Society (MMS) acknowledges the unsustainable escalation of health care costs.

The MMS will partner with other stakeholders to address system-wide mechanisms to control the forces responsible for the escalation in health care costs. These include among others:

a. improving the market structure for medical services through transparency of price and outcomes

b. encouraging the development of guidelines in diagnosis and treatment of conditions where evidence-based approaches are not yet available

c. suggesting insurance reform mechanisms to reduce consumer purchase of marginally-useful service, likely through higher copayment for such services

The MMS encourages a pluralistic compensation system to include fee-for-service, salary, and limited pilot studies that utilize global payment system. 

The MMS acknowledges that the fee-for-service system has positive value in the payment for medical services.

The MMS will continue its strong support for medical liability reform to reduce the waste resulting from over utilization resulting from defensive medicine. 

The practice of defensive medicine is a major contributor to rising health care costs and liability reform should be a priority in health care reform legislation. 

Ideal Payer System

The Massachusetts Medical Society (MMS) defines an ideal payer system and the definition encompasses goals that include:

  • universal coverage of population;
  • coverage of preexisting conditions;
  • accessibility to everyone regardless of location or background;
  • portability for all medically necessary services; and

The MMS definition of an ideal payer system encompasses comprehensive services, that include:

  • acute and chronic illness care;
  • prevention of disease and disability by risk assessment and education to change behaviors that may lead to disease or injury, early disease detection and treatment: to prevent, diminish, compress, and delay its disablements;
  • rehabilitation of disabled persons: to improve their function for work and living;
  • immunization;
  • counseling;
  • unimpeded access to appropriate specialty and subspecialty care; and

The MMS definition of an ideal payer system encompasses qualities, that include:

  • efficiency/cost-effectiveness;
  • equity/fairness, convenience and satisfying;
  • maximal patient and physician involvement, choice, mutual decision-making, and respect;
  • use of appropriate technologies, scientifically assessed for the needs of patients;
  • continuous improvement efforts for better health care;
  • outcomes through: practitioner education, at the undergraduate, graduate, and continuing medical education levels;
  • research;
  • reorganization of processes of care;
  • professional self-management, internal to the practice;
  • voluntary participation of physicians and patients;
  • maintain freedom of physicians to contract directly with their patients;
  • individuals retain right to establish medical saving accounts and to purchase catastrophic health insurance from insurer’s of their choice
  • maintain freedom of entry into the health insurance market; and

The MMS definition of an ideal payer system encompasses characteristics for payment of services and insurance, that include:

  • simplicity: uniform administrative criteria for eligibility and billing, single forms, and a single open formulary;
  • accountability;
  • consistency in benefit coverage limitations related to scientific evidence and expert opinion;
  • timeliness;
  • responsiveness: correction of defects; and
  • appropriate funding

Massachusetts Health Reform Law

The Massachusetts Medical Society (MMS) will continue its efforts in support of the implementation of the Massachusetts Health Reform Law (Chapter 58 of the Acts of 2006), working in concert with appropriate entities.

That the Massachusetts Medical Society (MMS) take the position that our representative on the Massachusetts Payment Reform Commission advocate for payment reform in a manner that is consistent with the goals of access, quality, and cost, and that payment reform include a model of fee-for-service medicine that allows the patient and physician to be aware of the cost of interventions and the ability to factor this into health care decision-making.

The Massachusetts Medical Society (MMS) supports the achievement of universal insurance coverage and adopts the five principles from the Institute of Medicine’s report Insuring America’s Health: Principles and Recommendations:

i. Health care coverage should be universal.

ii. Health care coverage should be continuous.

iii. Health care coverage should be affordable to individuals and families.

iv. The health insurance strategy should be affordable and sustainable for society.

v. Health insurance should enhance health and well-being by promoting access to high-quality care that is effective, efficient, safe, timely, patient-centered, and equitable. (HP)

The MMS will continue to investigate options that work toward the goal of achieving universal insurance coverage, that may include:

a. A non-disruptive and evolutionary approach to improving our current health care system, that is politically and economically viable and sustainable, and that includes quality and public health components.

b. The development of health care coverage products that are sufficiently comprehensive to provide meaningful health care, and that are affordable and can be obtained through appropriate purchasing pools for individuals or smaller employers.

c. A bi-modal approach of expanding public and private payer responsibilities; patients should have a choice between private and public financing.

d. Efforts to enhance current enrollment of Medicaid-eligible individuals and families, including appropriate opportunities through public and private entities.

e. Both individual and employer mandates, provided that affordable private health insurance and/or appropriate subsidies are made available.

f. Collaboration across all health care segments, including employers, health plans, health care organizations, legislators, and the administration for the State.

g. A single-payer health care reform as an option for achieving universal, comprehensive, equitable, patient centered, sustainable, and affordable health care for our patients.

The Massachusetts Medical Society will utilize existing research and data to explore various options for providing universal access to health care, including single-payer, and convey this information to Society members.

The Massachusetts Medical Society strongly asserts that the fundamental goal of any change to the American health care system should be to provide universal access to medical care for all Americans.
Any proposed change to the American health care system which will decrease the likelihood of movement towards universal access to health care for all Americans will be strongly opposed by the Massachusetts Medical Society.

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