Andrew Dreyfus, Executive Vice President for Health Care Services at Blue Cross Blue Shield of Massachusetts, says measuring and improving quality of care based on scientific evidence is central to health reform:

Much of the national debate on health care reform has focused on expanding coverage and controlling health care costs. There has been little discussion, however, about the need to improve health care quality. Much more than an afterthought, quality is an essential part of reform, the third leg of the stool to accompany access and cost. Possibly because the meaning of “health care quality” is not commonly understood, the important ideas behind that phrase are lost in the discussion.

To the health care consumer, “quality” may mean several different things, including wait times, the reputation of a doctor or institution, or whether equipment is modern and cutting-edge. All of these elements may be meaningful to an individual patient encounter, but they do not add up to characteristics of a high quality, reliable health care system.

Organizations committed to improving our health care system use a very different definition of health care quality. That definition focuses on care that is grounded in the available scientific evidence; that includes recommended preventive care; that achieves the best possible health outcomes; that takes into account the individual needs and preferences of each patient; that is delivered in the most appropriate setting; that includes no unnecessary or harmful services; that can be relied on to provide the right care in a technically proficient and caring manner.

Defining and measuring that kind of quality is not easy, but is essential to understanding what works in our current system, and improving what does not. Read more…

Earlier this month, the Special Commission on the Health Care Payment System recommended that the Commonwealth move to a global payment system. The recommendation has given us all reason to step back and imagine how health care might look different than it does in today’s fee-for-service world.

Our current fee-for-service system imposes an artificial, anarchistic structure on the relationship between doctors and patients. In that artificial structure, care must happen in the office. Coordinating treatment among multiple clinicians does not count as care. E-mail, in most cases, does not count as care. Specialty care is worth more than primary care. Treating disease is worth more than preventing it. Intensive procedures and high-tech care are worth more than a conversation between a doctor and a patient. And on and on until good care often is being delivered in spite of, rather than because of, the health care system.

Under global payment, this artificial structure is gone. We are hearing from the physicians and hospitals in our new Alternative Quality Contract that the global payment has liberated them from the fee schedule and all its unintended consequences. Under global payment, they are free to deliver care in the ways that work best for patients and their doctors.

Dr. Barbara Spivak, president of the physician group affiliated with Mt. Auburn Hospital, Read more…

Too often, debates over public policy reduce complex issues into polarizing political slogans. This is happening in health care, both here in Massachusetts and on the federal level.

Earlier this month, the Boston Globe ran a story on the state Payment Reform Commission’s recommendation that we begin to move away from our fee-for-service payment system to one that rewards quality and efficiency through “global payments” for providers. By the end of the day, there were more than 150 comments posted online; most criticized the Commission’s recommendations, some asserting that it would lead to “Soviet-style” health care.

Similarly, when a proposal was made to include $1.1 billion in comparative effectiveness research (CER) in the federal stimulus bill, some groups in Washington quickly derided it as an unwarranted infringement of the doctor-patient relationship and the beginning of the rationing of health care. These criticisms continue and are intensifying. A recent New York Times article referred to CER as a “medical minefield.”

What these two proposals have in common is the speed and intensity in which critics reduced them into simple and incendiary arguments. Another common element? Both have the potential to improve the quality of care and slow the growth of health care costs: CER by telling us which treatments will help people the most and global payments by providing incentives for using those treatments that will result in better outcomes. Read more…

In a front page story in the New York Times this week, reporter Kevin Sack suggested that the Commonwealth is facing “a day of reckoning.” We must confront our health cost problem, the article suggested, with the same vision and leadership that led us to embrace the challenge of coverage reform three years ago.

As contributors to this blog have written, there is little debate that the cost problem is urgent and threatens the sustainability of our pioneering coverage law. And most experts point to the same root causes of our rising spending: the growing incidence of chronic disease, the rapid introduction and spread of new medical technology, and the explicit incentives and expectations in our system that more care equates to better care – which can lead to unnecessary and even harmful treatment.

Conventional wisdom suggests that the consensus then breaks down: we might agree on the sources of the cost problem, but we will never agree on solutions. Some argue that it just too complicated and that competing interest groups are unwilling to compromise. We forget however, that this same skepticism plagued our early debate on coverage. Read more…

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. Read more…

As Brian Rosman of Health Care For All noted on Wednesday the call for payment reform was a constant refrain at the BCBSMA Foundation’s Summit on Tuesday. And the theme echoed far beyond the walls of the Kennedy Library.

• The Boston Globe editorialized that day that “the root of the problem afflicting medicine throughout the United States [is] a piecemeal approach to reimbursement that elevates individual procedures by specialists over care coordinated by a primary-care doctor” .

• The same day in Washington DC, RAND researcher Beth McGlynn told the Senate Finance Committee that “our methods of paying for health services are not aligned with the objectives of delivering high quality.”

While the consensus on payment reform has developed primarily because of rising costs, it’s important to note that payment reform does not seek solely to address affordability; Read more…

Discussions of health care quality often center on physicians and hospitals, with too little attention to patients and their families. But one local organization, the Dana Farber Cancer Institute, has put patients exactly where they belong in the quality movement: everywhere.

Readers of this blog are likely familiar with the tragic series of errors that led to chemotherapy overdoses at Dana Farber in 1994. What you may be less familiar with is Dana Farber’s exceptional commitment to patient and family-centered care, a commitment which grew even stronger as they worked to ensure those tragedies would never be repeated. Read more…

Capitation – a fixed, prospective payment to a health care delivery organization – was tried and then mostly rejected in the 1990s. Physicians and patients feared that it would lead to limits on choice and denial of needed care. The negative reaction to capitation was so strong that Joe Dorsey and Don Berwick recently called capitation one of health care’s “dirty words”.

Capitation earned much of its negative reputation because, as Dorsey and Berwick point out, insurance companies too often “claimed to manage care but in many cases only managed money.” Payment levels were set artificially low, and the system had little way to monitor the quality of care and watch for patterns of under-use.

We should not, however, let capitation’s failings prevent us from learning lessons from its successes. Scattered among the bad experiences of the ‘90s were innovations that resulted from capitation’s original design: aligning economic and clinical incentives to promote creativity in delivering the best care for patients. Read more…

Readers of this blog are well aware of the growing debate in the Commonwealth about how to slow our health care spending, sustain health care reform, and relieve a growing burden on employers, consumers, and government. Many of the proposed solutions – improved prevention and management of chronic illness, administrative simplification, and greater transparency of cost and quality information – have great potential. But their potential will be severely limited if they are not built on a payment system that rewards the best, most affordable care. We do not have such a system in Massachusetts today.

Last January, BCBSMA CEO Cleve Killingsworth challenged the company to examine how our method of paying hospitals and physicians could be transformed to better support the high quality care we all know our system is capable of delivering. Currently, Blue Cross and most other health plans base payments principally on the number of services provided, and the complexity of each service. For example, surgical and specialty care is rewarded more than primary care, and hospitals receive higher reimbursement when they perform more tests and procedures. As Karen Davis, president of the Commonwealth Fund, has written, “Fee-for-service payments create incentives to provide more and more services, even when there may be better, lower-cost ways to treat a condition…It’s not realistic to tell hospitals and doctors that they must improve quality if by doing so they are likely to lose money.”

What Cleve asked us to create was a system that would instead base payment on quality, outcomes, safety and efficiency – Read more…

Regular readers of this blog are quite familiar with the emerging discussion about health care costs in Massachusetts, a discussion which has focused mostly on the sustainability of health care reform in the face of rising premiums and higher than expected CommonwealthCare enrollment. Rick Lord, CEO of Associated Industries of Massachusetts (AIM), yesterday captured the growing consensus in the Commonwealth: “We’ve made great progress in Massachusetts expanding access to coverage, but we have to tackle the second phase of health care reform – we have to control cost increases or our reform is not sustainable.”

At the same time, a parallel national debate is intensifying over similar pressures facing the federal Medicare program. A recent Congressional Budget Office report suggested that answers must be found that improve the value of health care: “Substantial evidence exists that more expensive care does not always mean higher quality care. Consequently, embedded in the country’s fiscal challenge is the opportunity to reduce costs without impairing health outcomes overall.”

As we attempt to sustain health care reform, we must seek similar solutions: reducing costs while continuing to improve health outcomes. Read more…