Marching, Exactly Where? Moscow, 1 Fear.
Wednesday, November 21, 2018
What's up? Well, the theory is that risk-based payment mechanisms similar "accountable care, bundled payments as well as other contracts amongst the potential for rewards or penalties based on lineament performance as well as improve terms control" volition convey nigh greater efficiency as well as higher lineament inwards the wellness assist system. It is argued that the electrical flow system, mainly based on fee-for-service schemes, leads to overtreatment as well as waste.
In the midst of all the excitement, at that spot are rattling few thoughtful observers who heighten questions nigh the march.
I've devoted a lot of columns hither to the unanswered questions as well as potential unintended consequences associated amongst opportunity contracts. I've also been difficult on the wellness assist manufacture for a lack of analytical rigor when it comes to designing world policy prescriptions to bargain amongst ascent wellness assist costs. I don't wish to learn through all those arguments now, but let's but outline but about every bit nonetheless unanswered concerns:
1) As opportunity is shifted from insurers to providers, what adjustment volition move made inwards the insurers' terms of business, as well as how volition those adjustments move passed along to consumers. A reduction inwards opportunity should move accompanied past times a reduction inwards working capital missive of the alphabet reserve requirements of insurers: How as well as when volition those huge investment accounts move reduced as well as redistributed to the public? Likewise, if payments are made on the solid soil of annual population rather than private claims, when volition the insurers halt adjudicating claims information as well as trim down the size of their staff involved inwards these functions? When as well as how volition those savings move passed along to consumers?
2) The decisions past times ACOs to accept on to a greater extent than opportunity is already driving mergers as well as acquisitions every bit those entities endeavour to expand their opportunity pools. That marketplace concentration acts to growth the leverage of the providers over local insurers, driving upwards rates (whether fee-for-service, capitated, or bundled). How tin give notice nosotros move sure that whatever savings powerfulness emerge from opportunity contracts are non offset past times the greater marketplace ability of provider groups vis-a-vis insurers?
3) What volition move the internal distribution of opportunity as well as vantage for the diverse physician specialties inside ACOs? How volition that negotiation accept place? Is at that spot whatever ground to believe that the electrical flow fee schedules which offering higher relative payments to proceduralists than cognitive specialists volition non cast the base of operations for ACO internal transfer pricing? If at that spot is a surplus inside an ACO, which doctors volition learn which share? Likewise, if at that spot is a deficit?
4) Similarly, what volition move the internal distribution of opportunity as well as vantage for the diverse entities inside ACOs--the 3rd assist centers, community hospitals, multispecialty clinics, as well as post-acute assist facilities. If at that spot is a surplus inside an ACO, which facilities volition learn which share? Likewise, if at that spot is a deficit?
5) What volition move the governing construction of ACOs? If, every bit is oftentimes the case, the large 3rd centers agree the cards, how tin give notice the other players inside the ACO remainder assured that they volition move treated fairly inwards matters of opportunity as well as vantage allocation?
6) And finally, if lineament metrics are non properly drawn, don't risk-based contracts offering the potential for undertreatment of patients, swinging the pendulum likewise far inwards the other direction?
“If all you're going to create is you're going to spot providers at opportunity for cost, but you lot don't take away maintain a robust organisation for standard quality, as well as hence you're non leaving patients improve off,” said Dr. Ashish Jha, a Harvard University wellness policy professor.
We are all pleased, of course, to run into the next sort of optimism:
“As a doctor, I am rattling excited nigh the administration this is going,” said Dr. Stephen Ondra, main medical officeholder of Health Care Service Corp. “For much of my career, payers as well as providers had an adversarial human relationship that oftentimes created win-lose choices.”
But I fearfulness that Dr. Ondra as well as his like-minded colleagues are naive. The adversarial human relationship he sees today may rattling good move replaced past times a novel laid of adversarial relationships--between physician specialties; betwixt 3rd as well as other wellness assist facilities; and, sadly, betwixt patients as well as ACOs. The main drivers of wellness assist costs are non overuse related to fee-for-service care. As I take away maintain noted here, they get-go amongst the changing demographics of society. Fee-for-service is means downward the list. Quoting myself:
If nosotros were beingness rational as well as rigorous nigh policy prescriptions, nosotros would rank monastic enjoin these causes as well as decide the costs as well as benefits of policies that powerfulness offset them. For example, nosotros cannot alter demographic patterns, but it could brand sense to innovate world wellness programs to promote exercise as well as proper nourishment. We could alter the compensation organisation for primary assist doctors hence they could pass to a greater extent than fourth dimension amongst patients. We could subsidize physician teaching hence they wouldn’t take away maintain to earn hence much to pay off loans. We could reform malpractice laws to trim down defensive medicine. And nosotros could for certain engage inwards full-scale procedure improvement preparation of doctors as well as implementation of those techniques inwards hospitals to trim down the extra medical costs associated amongst harming patients. (Those of us who take away maintain done the latter take away maintain demonstrated conclusively the terms savings, non to advert the mortality as well as morbidity benefits.)
But, our world policy leaders take away maintain non done this. Instead, they assert that pricing-based over-treatment is the telephone commutation problem, as well as they offering capitated charge per unit of measurement plans as well as bundled payments every bit the solution. If you lot await closely, you lot volition bring out that most of those proposals come upwards from payers, either insurance companies who take away maintain a corporate wish to shift opportunity to providers or regime officials who are trying to trim down appropriations. Or from economists, who take away maintain a vogue to simplify marketplace behaviour as well as blame everything on pricing regimes. As I take away maintain said, when you lot take away maintain a hammer, everything looks similar a nail.
We shouldn’t dismiss a alter inwards the payment organisation but because it powerfulness create goodness the insurers or the government, but nosotros also shouldn’t adopt it but for that ground -- or because it fits into economists’ idealized models. Instead, nosotros should decide how large a component of the over-treatment occupation comes from the payment organisation versus other causes. And as well as hence nosotros should rigorously review the experience of such regimes as well as evaluate their costs as well as benefits. We should also decide how practical it is to implement a novel pricing regime.
I take away maintain a deep seated feeling that the march that is seen every bit hence optimistic today powerfulness get-go to experience to a greater extent than similar Napoleon's assail on Moscow, nicely represented inwards the nautical chart higher upwards from Edward Tufte.