HCI3 Update from the Field: Why is there always a tendency to go for the “or” instead of the “and”?

Submitted by francois.debrantes@hci3.org on Friday, September 7, 2012 - 12:28

Newtown, CT – September 7, 2012

Why is there always a tendency to go for the "or" instead of the "and"? Policy experts, physicians, health plan leaders and many in the industry shape their positions and strategies as alternatives. And yet decades of experimentation in healthcare should have taught everyone by now that there isn't a single alternative that will work. We need a combination of efforts that will dovetail with each other, some working for some areas of care and some providers and some working for others. After all, there isn't a single solution for anything anywhere else in the economy. We often hear the advocates of the PCMH tout its supremacy over other approaches, and in fact some health plans or purchasers refuse to do anything else (hey…what about all that specialty and surgical care not covered by PCPs?). Similarly, the advocates of today's version of capitation espouse its virtues as the only viable solution (hey…what about all those specialty cancer, mental health or child care centers? Do you simply carve them out and forget about them?). And finally, some advocates of bundled payment see it as the solution for all aspects of health care (hey…do you really want to bundle a tibia fracture or the flu?). The truth is more complex, and the solutions have to be more nuanced. It's not a matter of "or", it's a matter of "and".

What this means to you – An Issue Brief released yesterday by RWJF transcribes a conversation I recently had with Bob Berenson of the Urban Institute on bundled payments and global capitation. In it, we try and go through the pros and cons of both approaches, recognizing that each model has strengths and weaknesses, and that neither is a perfect solution for all that ails healthcare. And in this month's Health Affairs, there are hails of success from PCMH experiments and wringing of hands on other potential payment reforms (what a surprise!). Overall, there is one clear and unambiguous signal: we are moving away from fee-for-service. And while there is uncertainty about the effects of all these changes, there is certainty about the movement. Our lessons to date are clear: we need an "all of the above" approach to payment to match the subtleties and complexities of medicine and the delivery system. Let's embrace this diversity, learn how to blend the approaches, and get rid of "or".


Francois de Brantes
Executive Director
Health Care Incentives Improvement Institute, Inc.
w: www.hci3.org