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.
