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Six Bold Predictions About The Looming Health Reform

Dr. Marc Bard of Navigant

On Tuesday, Dr. Marc Bard, chief innovation office in Navigant’s health care practice, explained five key points about the Accountable Care Organization, the coming thing in Massachusetts health care if the Patrick administration has its way. Today, Marc makes six bold predictions about what will happen as the state attempts its next major phase of health care reform:

1. New partnerships will sweep across the landscape.
The academic medical centers lack the primary care base they need to provide fully integrated care, and of course community health systems lack the high-level tertiary care; neither one of them can be a complete system of care. So the first thing you’re going to start to see is more consolidation. You’re already seeing it on the insurance side with Tufts and Harvard Pilgrim merging, and you’re going to start to see it with providers. And that’s going to call into question restraint of trade and get the attorney general involved, because some of these systems are going to look closer and closer to monopolies.

2. More tension in the system
In today’s’ environment, for the most part, providers of care are contractually pitted against payers of care. They’re a little like dogs and cats. They’ve never gotten along terribly well for obvious reasons, and they generally didn’t mind battling each other.

Now, what is being proposed in Massachusetts creates somewhat of a zero-sum game, doctor against doctor and doctors against hospitals; and that’s a less comfortable battle. And, it’s potentially going to be even less comfortable because with the ACO, there’s going to have to be more support for primary care, and if you’re operating with a fixed global payment budget, that means that the high-end providers, the high-end physicians and hospitals, are going to take the greatest haircut. That’s reality.

And by the way, I’m a strong advocate of capitation. Of all the payment strategies that have been used over the past decades, the one that truly fostered innovation was capitation, because it required the invention of new ways to deliver care on a fixed budget. So I like responsible capitation, it’s just that I’m realistic enough to appreciate that introducing it in Massachusetts is going to be very difficult.

Think of a bell-shaped curve. There are people at one end who absolutely need the high-end procedure and no one would dispute that. At the other end, I don’t need a total hip replacement. But there are a lot of people in the middle of the bell-shaped curve. The real question is: Do they need the procedure and do they need it now? And those kinds of borderline cases are going to come under much greater scrutiny. Who really needs a stent? Who really needs a bypass? What’s the data to support bypass vs. stent? The best example is Prostate Specific Antigen testing for men. There are going to be long-term studies that ask the question, who really needs surgery or radiation and if so, when?

3. The Massachusetts reform will go a major step farther than federal health reform on ACOs. Continue reading