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The Philosopher King Approach to Health Care Payment Reform: Commissions, Councils, Task Forces, Panels and Lawyers

Paying for it is a whole new kettle....
Now that the U.S. Supremes have confirmed the Affordable Care Act as the law of the land, the Next Big Step - as the Disease Management Care Blog predicted - is the move from insurance reform to payment reform. While it's politically easy to broaden entitlements to cover everyone, figuring out how to pay for it is a whole new kettle of financing fish.

In response, a who's who of Obamacaregineers are stepping up with their Phase II recommendations for payment reform.  While you ponder whether the DMCB summary below is enough or whether you need to follow the link for more detail, ask yourself what's missing......

1. Let public and private payers combine forces to "negotiate" payment rates that aim for global spending targets at a regional level.  Embedded costs for research, training and uncompensated care would be carved out and preserved separately.

 2. Use bundled payment methods for episodes of care that span rehab and post-discharge care, starting out with cardiology and orthopedics. Aim to make this payment approach the rule for 75% of Medicare's budget within 10 years.

3. Commoditize medical devices, lab tests and radiology services by forcing suppliers to competitively bid for Medicare's business.

4. Encourage tiered insurance products, where consumers can pick progressively lower premiums in exchange for higher out of pocket costs.

5. Leverage state exchanges to ratchet down costs on pain of being "delisted" by forcing them to compete on cost and quality.

6. Simplify administrative costs by establishing a single format for all paper and electronic forms. The latter is the default unless the consumer opts for paper.

7. Make the pricing for medical services public and outlaw gag clauses.

8. Allow non-physicians to take advantage of scope-of-practice  laws to practice medicine autonomously.

9. Close the provider self-referral loopholes that allow docs to provide "in house ancillary services," unless its under a global cap.

10 Start all the above with the Federal Employees Health Benefits Program (FEHBP).

11. Use the "safe harbor" of practice guidelines to protect docs against allegations of medical malpractice.

What's missing is the usual emphasis on primary care and, in particular, the patient centered medical home.  While it could be argued that global targets and bundled payment methodologies will drive the inclusion of higher value/lower cost non-specialists, the DMCB is shocked, shocked that the experts and editors missed usual nod to primary care.

The DMCB will also point out that the proposal is rich in expert councils (to set spending targets), programs (as in Medicare Acute Care Episode to define the bundling), panels (for the competitive bidding and guidelines) task forces (for the administrative simplification), commissioners (to assure transparency) and, last but not least lawyers (expanding Stark to ban self-referral).  Plato, the champion of Philosopher Kings, would be proud. 

In the meantime, Ayn Rand is rolling in her grave.

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