Comments On the State’s Road to Payment Reform

By Lynda Young, M.D.
MMS President-Elect

Lynda Young, MDEarly next month (Jan. 5), the ad hoc committee advising the state Health Care Quality and Cost Council about payment reform legislation is scheduled to meet again, perhaps for the final time.

We expect that the committee will use the meeting to finalize its recommendations to the full Quality and Cost Council, which meets two weeks later. The committee’s discussions have illuminated the tensions, shortcomings and – dare I say – strengths of our health care system. If Massachusetts moves forward with payment reform, we must not only address these shortcomings, but also preserve what is already excellent.

I was appointed to the committee for two reasons: I’m going be president of the Medical Society next year, and I’m a pediatrician at a small practice in Worcester. This gives me a perspective that differs greatly from many members of the committee, so I saw my role as helping to ground the discussion in reality. As people spoke, I tried to think of the parents and children I see every day, and how the ideas floated at those meetings might affect my patients and their families.

I spoke of how, despite the obvious shortcomings in health care today, most people want to keep their doctors and their hospital. They want the best for themselves and their family, as we all would. And they treasure the freedom of choice that they currently enjoy. If payment reform threatens any of this, I doubt that patients will support it. And if patients don’t support it, failure is likely.

The committee’s work began in September. Discussions were framed by four separate documents prepared by the staff of the Executive Office of Health and Human Services. Some of the work was designed to focus discussion on such issues as state oversight of payment reform, and the rights of physicians and patients. Others sections seemed to be trial balloons, to test the reaction of committee members.

Many submitted written comments on each discussion item. Nobody pulled punches; many were strongly critical of some of those ideas, my organization included. Still, what struck me was the high degree of consensus among health care providers and health plans.

For example:

We agreed that Legislation must not force health care providers to join or form an ACO; it must be a voluntary act. While some physicians could move to a new payment system over a period of time, many will never be able to do so. Enforcing this by law would certainly worsen our physician workforce shortages throughout the state. There is too much diversity in our health care system to expect that a cookie-cutter approach will work. And when I mean diversity, I’m thinking of both physicians and patients.

That’s why flexibility is critical, on several fronts. We must foster the development of many kinds of ACOs, multiple payment methods, and multiple practice arrangements. One model won’t work for everyone. There must also be a willingness to make big mid-course adjustments when the unexpected occurs. Given the experimental nature of payment reform, I could almost guarantee you that there will be surprises, and some may not be pleasant.

That’s why state oversight should be exercised carefully, with flexibility and a light hand. We all recognize that the state must ensure fairness and a level playing field, to protect both patients and providers. The state is also the best entity to measure progress to achieving better cost efficiency, preserve access to care, and improve quality. But there is a very small body of evidence to guide us, and much of it isn’t likely to transfer well to Massachusetts. The best measure of success will be the results we see on the ground in our state, produced by many different approaches.

What will happen after the committee’s work is done? Clearly, we’ll see legislation at some point next year. But rather than marking the end of the dialogue, I really hope that it is the continuation of a critically important conversation that we have only begun.

This is an incredibly complex challenge, and the need to reduce costs is urgent. But last spring, the Legislature stopped short of submitting legislation, after realizing the enormity of the task. Health care hasn’t become any less complex since then. But thanks to the committee’s discussions, we have identified both common ground and important issues to discuss further. Let’s keep talking so that we produce a reform proposal that is responsible, evidence-based, and brings out the best in our health care system.

What are your thoughts? Please comment below.

  1. MD in MA says:

    Can someone explain to me why any patient would want to see a doctor who is going to earn more by doing less for the patient?
    The physician-patient relationship would be destroyed.

  2. Jerome Slate says:

    “The state must ensure fairness and a level playing field.”
    This is the state that closed the less expensive community hospitals and left the large players to “be responsible.” Political influence will ultimately win the day. Buckle your seatbelt.

  3. Bruce Bodner says:

    Tort reform is one of the keystones of ACO reform. If the doctors have to be the ones to trim spending by adhering to a global budget, then we have to be free of the imminent threat of lawsuit when the patient is unhappy that he is not getting his MRI or his heart surgery, but instead medications, or when he gets generic statin instead of Crestor. Otherwise its hopeless.

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