Health Care Reform - Progress

Health care reform is front and center at both the Federal and State levels. The prominent theme at the Federal level is universal coverage, that is getting a major portion of the 45 or so million people who are not insured to get coverage, and somehow do this without breaking the Federal bank. In reality, this is not health care reform but health insurance reform. It seems the words "health insurance reform" are being used by President Obama. The belief is that the health care system itself can be transformed through health insurance reform. At the Massachusetts State level, the focus is on payment reform to control costs. For all intents and purposes, Massachusetts has achieved near universal coverage, with less than 3% of the population uninsured, the lowest in the nation.

Federal Reform Initiatives

Key elements in the proposed Federal reform bill (House Version) entitled: "America’s Affordable Health Choices Act" include:

• Requires individuals to obtain and maintain health insurance coverage. Those who do not obtain coverage will pay a penalty of 2.5% of modified adjusted gross income above a specified level. Subsidies would be provided to low wage earners through a sliding scale of affordability credits.
• Creates a Health Insurance Exchange to serve as a marketplace for individuals and small employers to comparison shop among private and public insurers. The bill proposes the creation of a public health insurance option that is supposed to operate on a level playing field with private plans included in the "Exchange" offerings. The public option is the most controversial aspect of the bill.
• Prescribes essential benefit design and administrative rules for health insurance products. Insurance companies will no longer be able to refuse to sell or renew policies due to an individual’s health status or to exclude coverage treatments for pre-existing conditions. The bill also prohibits lifetime and annual limits on benefits and limits the ability of insurance companies to charge higher rates due to health status, gender, or other factors. Premiums can vary only based on age, geography, and family size. Health insurance plans would have to submit an application to become a Qualified Health Benefits Plan (QHBP) in order to participate in the Health Insurance Exchange program.
• Promotes primary care, mental health services, and coordinated care within the Medicare program through a Patient Centered Medical Home Pilot Program. A patient centered medical home provides patients with direct and ongoing access to primary care by a physician or nurse practitioner who accepts responsibility for providing first contact, continuous and comprehensive care to such patients. The medical home serves a coordinating role for all of a patient’s care needs.

Administration of the health reform plan would fall under the authority of a new independent agency in the Executive Branch called the Health Choices Administration that will be headed by a commissioner appointed by the President. The Health Insurance Exchange would fall under the auspices of the Health Choices Administration.
There are many more provisions and aspects of the America’s Affordable Health Choices Act contained in its over 1,000 pages. Given the uncertain nature of the bills future and the certainty that it will be modified, it is not worth delving into the details at this point.
　
Massachusetts Reform Initiatives

Given the relative success of Massachusetts’s universal coverage initiative over the past several years, the issue at hand now is cost, which is stressing the state budget and the private sector employers and individuals who must purchase health insurance. To address the cost issue, the State in 2008, mandated the creation of a Special Commission on the Health Care Payment System to "investigate reforming and restructuring the system to provide incentives for the efficient and effective patient-centered care and to reduce the variation in the quality and cost of care". The recommendations of the Special Commission were published and made public on July 16th. The report identified the perverse incentives of the Fee for Service (FFS) payment system as the main culprit driving costs. As stated in the report, "FFS rewards overuse of services, does not encourage consideration of resource use, and thus cannot build in limitations on cost growth". The Special Commission recommends moving to a global payment system.

Key components of the Global Payment system are:

• Develop Accountable Care Organizations (ACOs) that accept responsibility for all or most of the care that enrollees need. ACOs will be composed of hospitals, physicians, and/or other clinician and non-clinician providers working as a team to manage both the provision and coordination of care for the full range of services that patients are expected to need.
• Foster patient-centered care and a strong focus on primary care. ACOs will receive global payments and in turn will disburse those payments among participating providers, using methodologies, including episode based payment and medical home models, of their choice.
  Use pay-for-performance (P4P) incentives to ensure appropriate access to care, and to encourage quality improvement, evidence based care, and coordination of care among providers and across sits of care.
• Share financial risk between ACOs and payers. Payers, including private insurers and self-insured employers, will retain their current role as holders of insurance risk for health insurances contracts and employee health plans. To ensure that ACOs are not subject to insurance risk, global payments will be risk adjusted for clinical and socioeconomic case mix and geography. Clinical case mix adjusters will reflect patient’s health conditions and differences in consumer incentives associated with benefit design. Socioeconomic adjustments will recognize other patient characteristics such as income status, to the extent that they have been demonstrated to influence health.
• Encourage widespread adoption of medical home models of care. The Special Commission recommends that steps be taken to ensure that the primary care practices in each ACO undergo the necessary practice redesign to become effective patient-centered medical homes ad that they are compensated in a manner that supports their operation.
  The Special Commission recommendations call for implementation of the global payment system over a five year period.
  　
  How Will the Proposed Federal and State Health Reform Initiatives Affect the Marino Center?

In both the Federal and State plans, greater emphasis is placed on the role of primary care in the overall health care system and the idea of "Patient Centered Medical Homes". The Marino Center has long emphasized the value of primary care and is well situated to develop into a medical home as conceived by the reform initiatives. At this point, the Marino Center will be most impacted by the State initiative rather than the Federal initiative.

A key question for us is what organization will undertake the role of the ACO that the Marino Center will be part of and how we will fit into the overall structure of the ACO. Based on our current limited information, the ACO will likely be at the Partners Community Healthcare, Inc. (PCHI) level. This is the organization that encompasses all of the Partners Healthcare hospitals (MGH, B&W, Newton Wellesley, North Shore. Faulkner), and all physicians who are part of the PCHI network. Since the ACO will be assuming "performance risk", it remains to be seen how cost controls and distribution of funds will take place. With the emphasis on primary care, the Marino Center should play a larger role in the overall health delivery system. Further, we will be called upon to deliver on P4P quality measures. We are well positioned in this regard given the advanced state of our electronic medical system.

Our current strategy is to continue our focus on providing quality care and increasing our capacity to deliver more primary care services by expanding the number primary care provider resources.

The Role of Electronic Communication in Providing Care

Our society is moving rapidly toward communicating electronically using email and social networking tools such as Twitter, FaceBook, MySpace, etc. It is inevitable that this form of communication will have a greater impact on the delivery of heath care, especially for Primary Care services, as more patients use electronic means to communicate with their health care providers.

In theory, the electronic communication was supposed to reduce the number of phone calls that a doctor receives from patients seeking medical advice or for follow-up after an in person visit. At first this sounded great as it was assumed that doctors could respond more quickly to emails than engage in lengthy phone consults. However, as with many great ideas, there are unintended consequences. While there is some evidence that the number of phone contacts between patients and physicians has decreased, the complexity of the email communications have increased to a point where some patients are seeing this communication as a substitute for a face to face visit with their doctor. Clearly minor problems can be addressed in a quick and safe manner with a very succinct response by a doctor. Other more complex situations are a different story.
Obviously, in these cases the correct response is to not provide a detailed response but to indicate that a face-to-face visit is in order.

There are a series of questions that get raised in this brave new world. Where is the line? How do you define medical standards? How do you educate patients regarding the appropriate use of electronic communication? How do you keep this communication secure and private? How does a doctor get paid for providing this service?

At this point, some clinical practices, like the Marino Center, have established a secure messaging system that allows, and some might say encourages, patients to communicate with their doctors through an electronic format. However three significant challenges arise; one is the increased volume of emails and the time necessary to respond, the second is the length and complexity of the communication requiring more time and thought to respond, and the third is the lack of compensation for this service. While patients may like the convenience it does place an added burden on the doctor. This was not supposed to be the case.

Possible solutions the electronic communication challenges are to:

Not permit electronic communication at all
Limit the length of the message (like Twitter)
Assign a triage nurse or administrative assistant to screen all electronic communication and respond directly to the simple questions and direct patients to make an emergent or urgent visit, if warranted.

Under any circumstance, adequate payment for these services by third party payers should be required. This would provide an incentive for practices to develop this form of care delivery, which will happen one way or another.