Wednesday, March 11, 2015

Fee for Service and the Consolidationistas

 This post  will be need more background to be completely comprehensible. But I will pay that background foward by excising some of the referenced material and posting it later... Meanwhile I do not want to lose the thrust energy of the below thoughts--


First of all -- I am talking  about how I see the proposed reimbursement structure for single payer.  Yes,  HR686 and other discussions allow for FFS.  But what I see is a continuing thrust not only to lower the already inadequate reimbursements but to marginalize, if not eventually eliminate, the utilization of that process. 

 Pay for Performance, Global Budgeting, Accountable Care Organizations, etc are already being pushed as the main administrative structures.  And MediCare, et al, are setting targets for enhancing this process.

As I see it these structures are being pushed as if they are already proven approaches.  This is far from true.  In vivo they are only retreads of Managed Care, Capitation , Case Rates, etc that proved such failures in the 90’s.   In research and logic they seem to primarily promote more administrative game playing in the service of  capturing income/profit at the expense of actual appropriate service delivery.

Further, it seems to me,  one of the largely unspoken drivers away from FFS is distrust of the professional—as if some big administrative agency can be held more accountable.  Do we need to appropriately monitor services for fraud and incompetency—of course we do.  But incentivizing ever larger corporate entities only makes it more difficult to hold them accountable.

All this would be moot, or, at least,  of less concern,  if  there were  actual co-committed efforts towards  sustainability and enhancement of FFS .  However, I certainly do not read the current environment (and tea leaves) that way. 

Two recent commentaries illuminate my concerns from opposing ends of the spectrum.   The first is Lessons from an Early Adopter  ACO  (free subscription may be required. ) This is from Open Minds—a Mental Health data advocate par extraordinaire,   that promotes- despite its own internal evidence to the contrary--  subservience to ACO’s as the only way to accrete the mountain of data that is seen as a good in its own right.   The second is from a  Don McCanne discussion of concerns about consolidators missing the point of interference with, not enhancement of, service delivery.

Anyway, I suspect much of this is falling on sympathetic ears.  But the main point I want to address is finding some way to enlarge this discussion.  I do not pretend to be in the know about all that is going on.  But, from twenty five years of public health, non-profit and political service and private practice it seems pretty clear to me that the corporatizing consolidationists continue to control the discussion and the actual people who deliver and receive the service are marginalized.   

Strong advocacy  for the efficacy and preference for FFS does not seem to be very visible.  I want to help change that. 

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