In this scheme (perhaps not the word with the best connotation) there seems like there would need to be a lot of disclosure about patient information. Are there concerns about patient privacy, and patient medical information having to pass through too many hands?
Ryan Richardson

I’m talking about our Medicare Advantage offering, Tufts Health Plan Medicare Preferred. Working closely with primary care physicians who provide care to nearly 75,000 seniors, we have been ranked third in the nation by the National Commission for Quality Assurance for clinical excellence.

I’m convinced the reason that our members have such a good experience with this product is that the providers with whom we work are committed to this approach.

In addition, there must be balances in the incentives. In this realm, physicians cannot be successful if they aren’t willing to accept the financial risk posed by their patients not doing well. A full-fledged embrace of this kind of practice can absolutely lead to higher quality outcomes, but only if the providers are thinking in a broader way about their patients. They must be committed to examining the patient experience beyond the initial encounter with the doctor. They also must have the technological infrastructure in place to use data in order to improve quality for populations of patients.

There is no question that this kind of an approach requires a desire to work collaboratively with health plans, an investment in practice resources, and a shift in thinking, but the rewards of improved quality of care and overall lower health care costs are real.

Right now, this is not a systemic solution to all of the ills of the health care system. There are too many variables and not all practices want to engage at this level with health plans. However, it is a reasonable approach and one worthy of further exploration.

James Roosevelt, Jr.
President and CEO
Tufts Health Plan

Is this the future of health care in Massachusetts? Or does this proposal represent a trip back to the future and a return to the days of capitation that simply did not work in the mid-90’s?

Quite frankly, it is too soon to tell. But BCBS’ proposal is an important — and welcome — jumping off point as we start to craft the future of health care. It has become clear that the traditional fee-for-service model is not the long-term answer to controlling health care costs. As a hospital community, we have long held the belief that a focus on quality is, in fact, the best way to reduce health care costs over the long term. But as we collaborate with the health plans to develop this new approach, there are a few key points to consider;

- Whatever we do, we cannot afford to disrupt our success. Massachusetts currently enjoys unprecedented achievement when it comes to delivering health care. What does this mean? According to a recent Commonwealth Fund analysis, no other state offers what we offer our citizens in terms of health care quality and health care access. Simply put, Massachusetts has among the highest scores on quality measures in the U.S. and rates second in the nation in assuring residents access to needed care. There is tremendous value in the system we have put together.

- As we embark on new payment structures, let’s be sure to offer providers choice. BCBS, to their credit, tout their initiative as voluntary. This is the right approach. Hospitals, health centers, physician groups and other providers come in all shapes and sizes and will have different capacities to adapt to the new models. Flexibility will be key.

- Technology is a must. It grows increasingly apparent that information technology will be a necessary and important part of quality improvement and cost control efforts. Speeding the transmission of accurate patient information to the point of need is critical for success in quality improvement efforts and efforts to manage chronic disease. Several efforts around the state are underway, which look promising in terms of putting this type of technology in place. But all stakeholders must decide if a commitment is there to bring the technology to every corner of the Commonwealth. This will require a significant investment.

- The doctor-patient relationship is paramount. We must remember that at the end of the day, the relationship between providers and patients is sacred and that no payment structure or proposal can get in the way of delivering the right care at the right time. If we forget this, then we threaten to erode the valuable health care delivery system now in place.

If together, business, hospitals, physicians, health centers, insurers, and others can remain focused on and address these issues, the BCBS model can succeed. It may change form, it may evolve, but it can work. The status quo, fee-for-service model, will likely not work as we move to curb health costs. Regulation is not the answer either. We must rethink, retool and move toward a payment system that rewards performance. The carrot will work much better than the stick when it comes to patient care and cost control efforts.

Blue Cross is to be commended for a bold entry into the areas of quality improvement and cost control, but it will take widespread commitment and collaboration to make it work.

Lynn Nicholas, President and CEO
Massachusetts Hospital Association

When will our state leaders allow the creation of a publicly administered insurance pool that cuts out the waste of the private insurance middleman? The public insurer could utilize a capitated payment system to reduce unnecessary care, as well as put into place many quality improvement standards. Every time this model starts getting serious consideration in the State House, certain “stakeholder groups” come along and crush it.

When will those of us who are being crushed by the high cost of health insurance and healthcare be “allowed” to take advantage of a truly nonprofit social insurance model to achieve maximum cost-savings? This policy approach is used with great success in many other places; we are we not allowed to give it a try here in Massachusetts?

This is a sensible choice that citizens and residents deserve to have made available to us. Individuals, families, and employers should have a right to a public insurance option along with the “option” of purchasing private insurance. At least teh state should make it available on a trail basis and see how it goes.

To learn more visit http://www.masscare.org/about

On the questions about variations in health status and how people care for their own health, the alternative contract we are proposing addresses this in several ways. To answer Jonathan and Ryan’s questions about members with different health conditions, the global payments will be adjusted for health status, to minimize any risk that doctors would focus only on healthy patients. For members like Richard, who work to maintain good health, we are designing health insurance products that include incentives for diet, exercise, taking medicine as directed and having recommended preventive screenings. These programs may be available directly through an individual insurance plan, or through your employer.

To respond to Jonathan’s second point about drivers of health care cost, we believe that improving quality has been shown to moderate cost increases by eliminating unnecessary care and ensuring prevention and early diagnoses. We also hope that this alternative contract will alleviate some of the administrative burden from physicians and hospitals, because the global payment should simplify payment and potentially eliminate the need for referrals. And, of course, even in a single payer system, reimbursement to physicians and hospitals would still have to be calibrated to encourage early identification and treatment of disease (which is why Medicare is making changes to its own payments).

Evan: you’re right that this proposed payment system will only work with closer coordination among different caregivers and institutions, which should reduce the fragmentation so many patients experience today. This will require some new ways of doing things, but the contract is designed to support that innovation.

Laurie, thanks for the great example of dieticians. They can offer very effective treatment (in terms of both health and cost), and can absolutely be integrated into the care system under this alternative payment model.

Finally, on the question of capitation, we were very conscious in developing this contract to learn from early experiences with fixed payments. Capitation asked hospitals and physicians to focus only on costs, while this alternative contract asks clinicians to focus on costs and quality. By combining the flexibility of a global payment with significant quality incentives, we hope to support safe, effective, efficient care.