Doctors and Payers Should Guide Healthcare Quality, Payment Reform

Pittsburgh expert tells the Oregon Health Forum audience that fundamental reform is needed not from health plans and health systems but from providers and purchases working together directly with Q Corp data.

There’s little incentive for insurers to support payment reform, according to Harold Miller, president and CEO of the Center for Healthcare Quality and Payment Reform, So it’s time that providers and purchasers work together with a neutral community facilitator like the Oregon Health Care Quality Corporation, which has trusted data on costs and quality.

The state can’t step into that role, he said, because it purchases healthcare services for 33 percent of the population, and is also a regulator and political entity with leadership changes every few years.

If insurance premiums had increased at the same rate as wages from 2002 to 2014, Oregon employers could have increased wages by 10 percent or hired 10 percent more workers, said Miller, who predicted Medicare, the biggest driver of the federal deficit, will be insolvent by 2028,

Healthcare won’t improve by better coordinating poor-quality, expensive parts. Accountable care organizations have hired more nurse care managers and put IT systems in place but “nothing really has changed and it isn’t working very well,” he said.

Current reforms don’t go far enough. He likes CMS’s new CPC+ -- a partial capitation model with predictable payments to providers and extra payments for acute issues that limit losses to the practice and makes primary care providers accountable for what they can control – but thinks it’s too complicated and limited to just 5,000 practices in 20 regions -- and requires private health plan participation.

Bundled payments to hospitals for hip and knee surgery are useful, but “what about everything else?” Bundled payments also provide no protection against specialists cherry picking patients or unnecessary procedures nor do they incentivize care in cheaper, non-hospital settings. Miller would rather see condition-based bundled payments.

Miller recognizes that “hospitals are critical for economic development” and not just for the jobs created. “Would you want to live in a community without an emergency room?”

But ERs have high fixed costs that generate profits by treating more patients. A more sensible approach would be for the community to pay a flat fee for ER services.

“That’s how we pay for fire departments. We don’t pay based on the number of fires put out,” he said, pointing to Maryland as a state where hospitals are doing better financially with fewer patients.

“We have too many hospitals and not too many other alternatives,” said James Raussen, director of the Oregon Educators Benefit Board, responsible for benefits for 150,000 public employees and their dependents.

Miller also believes that co-pays and high deductibles discourage or prevent patients from using primary care, preventive treatments and chronic disease maintenance medications – “what we want them to have,” he said. At the same time, there’s little or no incentive for patients to choose the highest-value providers for expensive services similar to the way they purchase airfares.

“If primary care is not working, the rest of the system won’t work well,” Dr. Evan Saulino, a family physician who cares for patients at the Providence Southeast Family Medicine Clinic a residency training site with an economically and culturally diverse patient population. Jan can be reached at [email protected].

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