Saturday, February 28, 2009

What is Needed to Unravel a Gordian Knot is a Bold Stroke—Access and Coordination

Today, Andy Wallace joins us with some concise advice on how to make our health care system work far better.

He comes with a special perspective; a highly regarded physician specialist, a former medical center executive (former CEO of the Duke University Hospital), a former Dean of the medical school responsible for the Dartmouth Atlas and Vice President for Health Affairs at the Dartmouth Medical School.

What is Needed to Unravel a Gordian Knot is a Bold Stroke—Access and Coordination
by Andrew G. Wallace, MD

Your Blog on February 24, 2009 makes the point that “cost containment is the whole ballgame” and I do not disagree with that emphasis. But you and others also have made a point in prior reviews that the consequences of being uninsured are unacceptable, even if they are only a symptom of a larger problem. I would add that availability of high quality coordinated services is sufficiently uneven today, based on geography, per capita density, and per capita income (in addition to insurance status) so that even universal and affordable insurance will be a shallow promise for many. I would like to suggest two elements of the necessary bold stroke to unravel this Gordian knot. Both suggestions actually would have getting better care to more people and partially offsetting cost reductions.

First would be insurance reform. I would propose an insurance connector with teeth. All health insurance, other than that through SCHIP, Medicare, Medicaid and other such programs for which an individual is eligible and enrolled would be through the connector. Everyone would be required to have health insurance with appropriate premium subsidies for lower income individuals or families. With such a mandate pre-existing conditions would not be a basis for any participating plan to either deny coverage or require a different premium for such individuals.

Each connector would offer choice from among a limited number* of private and public plans. However, any plan listed would be identified as either not-for-profit or for-profit, and it would list the percent of its premium paid to providers. Benefits and premiums would be described, but no entity would be on the connector if it didn’t offer at minimum a base of benefits agreed to ahead of time by the connector. Similarly, connectors would be informed annually of results from the new Comparative Effectiveness board, and any recommended procedure or treatment that did not meet their tests of effectiveness should be identified by the connector, and paid for by individuals out of pocket. Finally, to be in the connector all insurance plans must agree to use a common claim form.

* My sense is that to recapture any significant part of the significant “excess administrative cost” related to the plethora of private insurance entities, including excesses in doctor’s offices and hospitals in dealing with so many entities, the aggregate number of participating plans needs to be relatively small. To an extent we can look to competition inside the connectors, with other private and the potential public offerings to achieve that result. But more regulation may be required.

Furthermore, connectors at a state level, or even a large single one at a national level, would be large enough to allow to allow variation analysis of the type Wennberg and Fisher have applied so productively to the Medicare population. Such analyses could provide the opportunity to identify physicians or hospitals who generate expenditures on a DRG and or age basis, which exceed some defined level or the national average ± a percentage; hence qualifying as an outlier and flagging whether requested reimbursement by the connector plan is appropriate. I sense Obama and his advisors want to move in a similar direction with Medicare.

Thus, I see an appropriate connector concept as a powerful way to insure most if not all citizens and to attack many aspects of a cost containment strategy.

Second, would be system reform at the provider level. I am concerned that at some level responsibility must be taken to assure that all people who will have insurance also will have access to primary care and to a provider who can and will arrange access to specialists and hospitals when needed and coordinate subsequent care in the patient’s best interest. I am attracted to the possibility that not-for-profit hospitals within what the Dartmouth Atlas calls Hospital referral regions or (HRRs) are such naturally occurring loci for that responsibility. HRRs are regions defined by ZIP Codes where a plurality of patients is already referred to one or more acute care/tertiary hospitals within the HRR. These hospitals are under sufficient actual or potential leverage from either state or federal influence to accept that responsibility. The challenge at an HRR level is to either attract a sufficient number of primary care providers, or to provide them in the form of Federally Qualified Community Health Centers or Rural Health Clinics, in either case linked to the hospital(s) and specialists in the HRR to assure access and coordination. I think geography is a logical and reasonable way to take responsibility for a population. These hospitals, with some assistance from their state or from HRSA or even from their connector, could be leveraged to create these networks to assure access to care and its coordination. I believe that patients managed under such a coordinated system are a part of what the Commonwealth Fund and the American College of Physicians include in their visions for a “High Performance Health Care System.”

Furthermore, populations insured by a connector of the type proposed and participating in the type of coordinated system described offer a near optimal context for measuring the quality of outcomes and comparing ours to other countries.

According to Myth, what is needed to unravel a Gordian knot is a bold stroke!
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