The Time to Act is Now

On Wednesday, I spent my morning at the Health Services Cost Review Commission (HSCRC) in Baltimore listening and testifying to the proposed changes that will be occurring over the next several years to the health care delivery system in Maryland. It was the first in a series of ‘public comment’ sessions designed to help guide the eventual decisions and direction the commission will take.

For those unaware the HSCRC is a state regulatory body established in 1971, which establishes rates for all hospital, based services and comments on expansion of services such as certificate of need applications for new hospitals. It essentially controls the purse strings for all hospital reimbursement for the state through a ‘Medicare wavier’. Maryland is the only state on the US to have such a system.

During the testimony there were presentations on the current state of our health care system and the cost crisis, which is rapidly approaching regarding percentage of GDP being spent on health care. The proposed solution preferred by the director is moving towards a ‘bundled payments’ system. Essentially bundled payments take all the reimbursement expected for a particular condition and wraps it up in a single payment to the hospital. The hospital will then ‘parse out’ the payments to all the providers involved in the care of the patient. Is the hair on the back of your neck standing up yet?

The goal is laudable, concentrating payment and focusing everyone’s attention on critical issues such as quality of care, outcomes and cost efficiency. The method being pushed unfortunately leaves one major stakeholder out of the equation, physicians. A guest, Stuart Altman, invited by the commissioner to comment in support of his plan, mentioned that fact.

Mr. Altman is a health care guru who comments frequently on reform including in his home state of Massachusetts. The results in Massachusetts are not exactly stellar and he readily admits this fact. Care to guess who would be the winner in the bundled payments scenario? Think large hospital systems and you are getting warm. Mr. Altman described a preferred system called accountable care organizations (ACOs). ACOs are in their infancy and essentially take all the care being delivered to a group of patients; primary care, outpatient, inpatient, and home health care and bring it under a single multispecialty group of providers and hospitals to deliver that care. It will involve a shared governance structure of the physician groups and hospitals. It truly is a brave new world we are entering.

My point in describing these 2 models in some detail is to let you know that the big ball called health care payment reform is starting to roll down the hill. If you are not behind it directing it you may find yourself in front of it being flattened by it. It is also a time of great uncertainty. In that uncertainty there will definitely be opportunity for the group that is prepared and positions itself to take advantage of the changes. In general I think emergency medicine will be fine in the short term as more patients fall under some type of health care insurance coverage. We will no doubt see a rise in volume as patients seek care and are unable to find appropriate primary care services to access. It is the long term where I am less optimistic unless we see a lot more political advocacy on the house of medicine’s part.

The only group of physicians testifying included yours truly. There were 3 other emergency physicians, Bob Rothstein and Fred Thaler from Suburban, Bill Jacquis from Sinai and Jeremy Roth the current President of the Maryland Society of Anesthesiologists and a member of First Colony Anesthesiology group. 5 doctors (all hospital based) were the only physicians present to get on the record and voice our point of view. It was a powerful reminder that if you do not make your voice heard you might not like the end result. The Commission seemed very attentive to our remarks.

We all spoke about the safety net that is emergency medicine and how it is critical to maintain that safety net. I spoke about several issues but the most important point I hope I made is that the model of bundled payments as the primary or only solution to our health care challenges is too limited and restrictive. The result is that many physicians would be forced, perhaps not too strong a word, to become hospital based employees. Seeing how that worked in the past leads me to believe there may be a better option out there. I see other solutions to this issue.

I am reading a book called Switch by Chip and Dan Heath. It is all about change and the need to find ‘bright spots’ where the problem seems too big. In those bright spots are the solutions to the big seemingly unsolvable problem. I am sure there are many bright spots in health care delivery in our state. Indeed I believe MEP is one of those bright spots, but hey I’m biased.

We also need to realize that the time is here to acutely focus on the cost of care we all provide. The only way to defend the care we provide is to show that it is indeed cost effective for the presenting complaint, delivers great outcomes and has high patient satisfaction. All physicians and groups will need to pay attention to this fact as we move forward and coordinate care better. Another opportunity as emergency medicine stands at the interface between outpatient and inpatient based services.

There are, of course, a myriad of issues such as deficits in the physician workforce, fair reimbursement, on call issues, defensive medicine due to lack of tort reform and on and on. As is said in Switch that would all fall under TBU, true but useless, when it comes to addressing the problem at hand.

I must confess I didn’t go into emergency medicine to be in politics. Yet into politics and advocacy we ALL must go if we want to be part of this process and help guide where the system will end up. The more we have our voices heard, for all the right reasons, most importantly for our patients, the more likely we are to shape a system that maintains the traditions on which this country was founded. Namely hard working people passionately committed to an ideal and willing to risk much for a reward that benefits us all. Are you with me? Angelo Falcone, MD