Deppe, Silverman & Catapano-Friedman: All-payer plan is risky and counterproductive

Editor’s note: This commentary is by Susan Leigh Deppe, MD, of Colchester, Alice Hershey Silverman, MD, of Montpelier, and Lisa Catapano-Friedman, MD, of Bennington, who are psychiatrists with many years’ experience in private practice and other settings in Vermont.

Chasing Medicare’s unproven “quality” data and mythical cost savings ignores obvious ways to fix health care. The all-payer model is wrong for Vermont.

First, creating a single accountable care organization (ACO) privatizes enormous power, pushing us toward a single purchaser in the marketplace. Such private monopsonies are extremely dangerous. (In contrast, tightly regulated public health care monopsonies in most developed countries are beneficial to their populations. Whether single- or multi-payer, they care for everyone, spend far less than we do, and get equal or better health outcomes.) In a single ACO, large hospitals would gain even more influence relative to small practices. The Green Mountain Care Board (GMCB) was designed to be free of conflict of interest and to make budgetary and health care allocation decisions for all of Vermont. It should not abdicate this much responsibility and give it to any private entity.

Second, the ACO scheme takes risk from insurance companies — that’s the point of insurance — and dumps it on hospitals and clinicians. This is a bad idea for many reasons. Third, research shows we don’t know how to measure quality, and most ACOs don’t save money. Vermont’s Medicare spending is already relatively low. Fourth, spending millions on bureaucracy to track questionable “quality” measures is unconscionable when other needs are so great.

Fifth, administrative burdens on primary care and mental health clinicians will reduce access to care. These specialties, already drowning in administrative nonsense, will bear the brunt of new “quality” documentation. Private practices are small businesses, and are often the most cost-effective setting for care. Yet, because of low reimbursement, many private practitioners have quit, or have joined hospitals in order to survive. The private practice system is collapsing at the same time many Vermonters are desperate for care. Access to psychiatrists has been horrific for many years. We could reverse all of this by raising reimbursement and minimizing bureaucracy, but the all-payer proposal does the opposite! It will likely cut payment while requiring doctors to obsessively track useless “quality measures.”

Excessive focus on documenting “quality” could force clinicians to neglect other aspects of care. It is analogous to “teaching to the test” in No Child Left Behind. And some metrics punish clinicians financially for things over which they have no control: patients’ behavior, lifestyle or inability to afford medications and treatments. This is unfair and counterproductive. Clinicians might feel financial pressure to avoid providing care to difficult or complex patients.

Excessive focus on documenting “quality” could force clinicians to neglect other aspects of care. It is analogous to “teaching to the test” in No Child Left Behind.

 

We recognize that the incentives and penalties are being pushed at the federal level via Medicare, and now by other insurers, whether one joins an ACO or not. But we know of no other country whose health care system has this bizarre obsession with documenting “quality” — and we should use waivers to avoid it if possible. Most advanced countries ensure quality and manage costs by tailoring resources to population needs; strong regulation; having far higher ratios of primary to specialty care clinicians than we do; and price controls (including drugs, medical equipment and information systems.) Unified systems provide data that can drive appropriate care and technology use. They waste little time or money on administration because they lack the byzantine morass of private insurance, “managed care” and drug/device profiteering that devour our clinicians’ time and 30 percent of our health care dollars!

Rather than the all-payer waiver, we should pursue publicly-funded Universal Primary Care (PFUPC), including outpatient psychiatry, using federal waivers to include as many payers as possible. It would cost very little and could be designed so care is not blocked by deductibles and copayments. Relieved of that coverage, insurance companies would lower premiums for families, employers, schools and governments, reducing taxes. It would not cost much and the benefits would be enormous.

The Green Mountain Care Board could incentivize primary care and psychiatry, which save money and improve population health. Payment could be fee-for-service, salary, or time-based, since capitation doesn’t work in small practices. Offering a central, streamlined billing clearinghouse would reduce office overhead cost and allow doctors to spend more time with patients. More practices would survive, clinicians would be happier, and more would probably move to Vermont. Patients would have more access and choice. They and their doctors would be in charge of care.

While chasing “quality” and ACOs, we’ve been ignoring the obvious. Let’s exit the all-payer dead-end and get back on the road to universal primary care and better health.

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