Editor’s note: This commentary is by Steve May, a licensed independent clinical​ social worker who is the former national director of state affairs for the Hemophilia Federation of America. He is a member of the Selectboard in Richmond, where he resides.
[M]ental health practitioners have a name for them. We call them “the wounded well.” These are people who have a need for a mental health provider, but they aren’t our sickest clients; those folks are called “severe and persistently mentally ill (SPMI) clients.” In mental health especially, words matter. SPMI is supposed to be less stigmatizing for people being served by a mental health provider.
SPMI clients are chronically ill. They might have a more severe case of bipolar disorder or suffer from a chronic case of schizophrenia. Think of them as the mental health equivalent of chronic medical conditions like heart disease or diabetes. These conditions are all systemic. They are likely to need management and most likely will not come with a cure.
So I have to ask: With the inevitable transition to global payments and​ the all-payer model, why would I ever agree to see these patients. It’s not that I don’t think that they are entitled to care. I believe that they deserve the best care money can buy them, but as someone running a small business, there is absolutely no incentive for me to treat this population. More challenging and demanding clients will be more costly to treat because they will consume more services. This is true of any patient who consumes more services. Now that you have de-incentivized the fee-for-service model of payment for all health care providers, why wouldn’t I as a care provider cherry-pick healthier clients?
There is no incentive to treat anyone who is truly ill. That is the sad reality of global payments. If you are challenging, if your health needs make you somehow “remarkable,” then there is a massive disincentive built into the system, making it much more difficult for you to access basic and adequate care due to your ongoing health challenges.
Payment reform is well-intentioned enough. But we build these systems thinking about the majority of people, not thinking about all people. This will cost Vermonters. People with chronic conditions absolutely will have a more difficult time getting adequate care. They will likely find a health care universe that acts to dissuade them from seeking care, or seeking enough care, because to do so would result in exceeding their annual care allotment.
One of the most important parts of Obamacare was that it ended both lifetime and annual insurance caps on health care for everyone. Global payment is, in effect, the restoration of annual caps by another name. But instead of affecting just the patients whose care was costly because of the chronic nature of their care, now you are making health care providers complicit in denying their care because it’s a bad return on investment for the health care providers managing their global payments per client.
Global payments reduce the administration of health care services to nothing more than a crass business deal. After all, if you apply any other metric, global payments don’t work. They don’t work for patients who have care needs which are more basic than the most simple of care needs. It doesn’t work for the health care providers who are suddenly transformed into bean-counters looking for the most well “sick clients” they can find, because the shift in payments will result in less care being administered. Be clear, this is a form of rationing. Health care providers are being enticed to provide less care.
Less care, fewer procedures and better outcomes — that is the hope. But when less care ultimately results in more adverse circumstances, global payments will result in equally costly care to the fee-for-service model. It also will likely find providers reluctant to provide services.
It is certainly possible that this experiment will even result in Vermont providers abandoning their Vermont clients all together if the financial disincentives to provide care in Vermont are significant enough. We are bound to be left with practitioners remaining in Vermont cherry-picking their clients. There is no guarantee that chronically ill clients have a right to basic and adequate health care. There is no enticement for providers to provide care to chronically ill patients. There currently is no plan to exempt the most difficult to treat patient from the global payments scheme. Without exemptions, providers are penalized monetarily and in terms of their time because they could be using the time they are treating the chronically ill patients to treat more wounded well patients.
All around, global payments need more study. While payment reform is necessary to sustain the health system, the current plan for global payments as it currently exists will result in less care. It will also result in less care for those most in need of care. Together these factors create a cure which is far worse than the disease.