How often do a health care visionary from Cambridge and a five-term Senator from Montana reach the same conclusion on the same day?
At a conference on the health care quality movement last month, Don Berwick equated the dilemma of our current health care system to “the tragedy of the commons.” He suggested that as long as individuals work to maximize their own benefit — which is how our system impels people to operate — the public good is left unprotected, and ultimately depleted. (Thank you Elmer Freeman for such a clear summary of the full conference.)
Opening one of a series of Senate Finance Committee hearings on health care that same day in Washington D.C., Committee Chairman Max Baucus made a stunningly similar point. He noted that “John Donne wrote that ‘no man is an island entire of itself; every man is a piece of the Continent, a part of the main,’ but the way American pays for health care is driving healthcare providers to become islands unto themselves.”
In their remarks, both influential leaders pointed to similar solutions: changing the way we pay for care to end the fragmentation in the health delivery system, and reverse the incentives that promote volume of high intensity services over quality of care and population health.
If only we could reach a similar consensus here in Massachusetts. There is some good news on health costs. Most health leaders concur, for example, that slowing the growth of health care spending will require lowering administrative costs, preventing and managing chronic illness, and reviewing the cost-effectiveness of new medical interventions. But as a community we still resist the notion that these and other solutions require a foundational change in how we reimburse physicians, hospitals and other care providers.
Fortunately, our legislative leaders anticipated the need for payment reform, and included a commission charged with looking at this very question in the cost containment legislation passed over the summer. The Payment Reform Commission is slated to convene shortly, and not a moment too soon. With a clear mandate, strong leadership from co-Chairs Secretary Leslie Kirwan and Commissioner Sarah Iselin, and an aggressive timeline by which to report their recommendations, the Commission has a great opportunity to spur action on payment reform and solve the systemic problems presented by Don Berwick and Max Baucus.
Andrew Dreyfus is Executive Vice President for Health Care Services at Blue Cross Blue Shield of Massachusetts and former President of the Blue Cross Blue Shield of Massachusetts Foundation.
Your comments ignore those institutions that — under the current system of payment — have chosen to engage in precisely those steps you advocate. Your proposal also has the clear potential to reward the largest network of integrated healthcare delivery, enhancing its market power. Finally, you aim to shift the actuarial risk of insurance to providers and away from insurance companies that have the balance sheet to cover those risks. Perhaps those are reasons that a consensus has not emerged. You have to get past the generalities and deal with these issues — conducting a shared analysis of what it would take to make this really work for both the providers and the insurance companies.
As I re-read this, I realize that my second point was overstated and would give the impression that the plan is designed to favor one particular system. I don’t believe that to be the case, and I regret giving that impression.
The point I should have made was that this kind of plan could be easier to implement by those hospitals that have more integration among a variety of parts of the patient care spectrum — because it would be easier to coordinate care based on an annual rate per person if there is an integrated delivery system.
For a place like BIDMC, which is not part of a such an integrated system, it would take an extra effort to negotiate the payment and care system throughout the health care spectrum with a variety of institutions that are independent from us. This would require a new kind of risk-sharing arrangement with non-affiliated hospitals, skilled nursing facilities, and the like.
In contrast, for some other systems in the state — Caritas and Partners come to mind — it might be easier because of common ownership, information systems, and joint contracting among a variety of types of health care providers. That being said, even for them, there would also have to be an underlying risk-sharing agreement that was acceptable among their affiliates.
I apologize, however, for leaving the wrong impression in my initial comment.