Newtown, CT – February 8, 2013
The Good, the Bad and the Ugly….now playing at a health care spectacle near you – We've known for a while that activating consumer-patients and engaging them in intelligent and thorough discussions with their clinicians can only lead to good results, and this month's Health Affairs is replete with evidence of such goodness. In particular, work from our friend Judy Hibbard shows that there's a real payoff to activating consumers. Couple that with results from experiments of shared-decision making and VBID, and you start piecing together a much needed recipe to support a more rational demand of health care services. Of course, this is all (as we've learned painfully during the past decade) for naught, without a convergent effort to support a more rational supply of health care services. As Mark Fendrick is fond of saying, you need both the peanut butter and the jelly to make a good sandwich. And that's where it gets a little bad because the payment reform designs coming out of "the big payer" are blending too much insurance risk with performance risk. That point was made very clear in a recent paper published by MMRR: "Statistical Uncertainty in the Medicare Shared Savings Program". In a subsequent dialogue with the author, it's clear that to overcome the statistical uncertainty, ACO-type models like the MSSP need to have a far larger number of plan members (the min should be 20,000), and/or reduce patients with conditions that are highly infrequent and have high costs and high variability (not just all high cost cases above a certain percentile). The failure to separate insurance risk from performance risk leads us to the ugly – failure to take responsibility for one's action and continued harm to patients.
What this means to you – A little over a decade ago I worked with Judy and others at GE to design a program to activate consumers, and it worked, much like the results in the studies above suggest. And what we discovered pretty quickly is that the activation would be wasted on an inefficient and ineffective delivery system. So we set out to find and reward physicians that were good at managing patients with chronic conditions; we supported hospitals that filled out the Leapfrog survey; and we bundled payments to focus the delivery system on reducing waste caused by overuse and misuse and encourage reduction of underuse. And here we are in 2013, and the lessons are the same. Yet we still see the bad side of poorly designed payment programs creep up, and we see the ugly behavior of those who continue to be unaccountable to the populations they serve. To get rid of the bad and the ugly we must simply heed the advice of the experts in designing payment programs that focus providers on doing right, and push out the boundaries of public transparency of cost and quality. And then we'll be left with the good, and that's a spectacle we're all looking forward to seeing in every neighborhood. For more on what you can do, pick up a copy of the Incentive Cure.
Francois de Brantes
Health Care Incentives Improvement Institute, Inc.