Delivery waste rampant

The first panel at the Feb. 26 Providence Business News Summit on Health Care Reform & The Insurance Exchange was slated to review the consequences of Obamacare five years out.

And it started out that way, with Pannone, Lopes, Devereaux & West partner William E. O’Gara discussing some unintended consequences and open issues in the employer mandate. But then it quickly segued to the real issue in health care – the delivery system. No one should have been much surprised by this given the highly qualified people on the panel, some of whom have been grappling with the health care delivery-model conundrum for years. What do I mean by this?

Obamacare did many things, some good, some not so good. It greatly expanded coverage for those who cannot otherwise afford it. Good thing. It enacted a number of reforms for health insurers, again some good, some not so good.

But it has also created nightmarish rules for employers, at times incenting game-playing with the number of hours employees can work to get around the “full-time employee” issue.

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It also placed huge additional financial demands on an already overburdened system to cover what had been the uninsured and underinsured – what some refer to as wealth redistribution. What Obamacare did not do, however, is address the fundamental structural challenge of health care: to change how we deliver care.

The panel jumped feet first into that very issue with Blue Cross & Blue Shield of Rhode Island’s Dr. Gus Manocchia making the fascinating suggestion that with the right reimbursement and delivery-model changes, insurers could start to get out of managing care, something that has never been near and dear to physicians and that costs a lot of money for insurers with perhaps questionable results. He talked of building a “bridge” to a more integrated ACO delivery model.

The panel concurred and reinforced this message of integrated care.

Given time constraints, the panel did not get into the reimbursement changes needed to change delivery. Too deep in the weeds for then and there, but still crucial. They instead focused on the fundamental end result that was needed – integrated, accountable delivery of care focused on quality and outcomes – not on volume.

Manocchia underscored the need for delivery reform with the startling reference to the fact that upwards of one-third of all health care expenditures are waste – of no use or value whatsoever. Imagine? In Rhode Island alone, that constitutes more than $800 million, a tidy sum that might be better used.

Dr. Andrew Sussman, CVS Health MinuteClinic’s president, went one step further, suggesting new types of collaborations such as that between CVS and the Rhode Island Free Clinics, and MinuteClinics and patient-centered medical homes, which do not require merger or acquisition – only forward thinking by management, the will to do things differently, and coordination.

There are 980 MinuteClinics in this country, but until recently, none in Rhode Island. Perhaps with changed reimbursement, primary care physicians, instead of opposing MinuteClinic, can incorporate it into their patient-centered medical homes as a valued collaborator. This, ladies and gentlemen, is new for Rhode Island and it bodes well if it is acted on – dare I say, pursuant to a statewide comprehensive health plan?

I asked myself if anything has really changed. In past years, I wondered. But, I believe it has changed. This is the first time that I have seen such calm unanimity amongst the varied health care players on the panel, agreeing that the only way to succeed is massive integration of care via delivery system and payment system change. Now, to accomplish that is wicked hard, as we like to say. My point – when the top people at our best institutions are singing from the same hymnal, there’s cause to take notice and perhaps even hope, our state motto. •

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