Managed Care 101 in 2010 (Part XIII-c): Old Conversations Materializing into Current Topics

April 2, 2009

Here is an email discussion between a colleague and me about my value equation posted to a previous blog in this series (Part I-g).

From: Meyer S. (Academic Medical Group's Exec. Dir.) Sent: Mar 25, 2009 1:56 PM To: fitdoc@sprintmail.com Subject: RE: "One Cannot Measure What One Does Not Manage"

* I get Email alerts from the Commonwealth Fund

We go way back. Your "value equation" is typical Kaplan, but I don't disagree with your tenet. (Haven't you heard me describe quality, cost and access as a three-legged stool?) From your last post, it sounds like Karen Davis* is onboard, as well. The need to balance cost with quality and preserve, if not improve, accessibility is palpable, particularly now as we try to extricate ourselves from the current economic morass.

From: JGK Sent: Mar 26, 2009 5:57 AM

But, there's another analogy we need to resurrect—'When you squeeze the balloon, it tends to pop out somewhere else.' The point here is that when we have tried to squeeze down the costs for example, by putting providers at risk or hitting patients with large co-pays, we have run the risk of diminishing quality or impeding access. We've all seen the PCPs referring out stuff they could have handled because of the way they are paid; we've seen people putting off even non-discretionary care because they cannot afford a doctor visit. Just the other day, my mechanic was complaining that people are waiting on maintenance or 'early intervention,' only to have expensive repairs pop out (and OBTW he also is hurting for liquidity).

Meyer, are you seeing old conversations materializing into current topics? For instance, please take a look at "One Cannot Measure What One Does Not Manage."

From: Meyer Sent: Mar 26, 2009 18:55 PM

I did take a look at Part XIII and I am seeing old conversations materializing into current topics, but the problem is that I’m seeing the same old arguments used to discuss the old topics! In other words, Jeff, I’m not seeing a lot of progress on many of these tired issues and I am certainly not sanguine about health care reform these days.

Talk about the fractionalization of health care? It's the 'same old, same old' merde when it comes to transformation of the health care 'system—protecting the status quo, specialists generating visits and primary care being capitated, cook-book medicine, process evaluation, not critical outcomes, etc.

The following, however, are possible exceptions:

• The need for comparative research (head to head trials) that managed care has been screaming about for years. (I wonder who, by the way, would intentionally keep prescribing something that has been found conclusively not to work as well or is less safe than as something else?) I’ve watched this get twisted by talking heads into a referendum on rationing. Hopefully, the stimulus package may jump start this research by govt. and private entities.

• The need for bio-similar versions of high-cost biologics. New legislative proposals are being worked on this year.

• The need for new benefit models to address unrealistic patient cost sharing for high-cost biologics.

• Value-based health care—increasing number of educational sessions and papers are surfacing on reaching this goal.

I’m sure there is many more, Jeff!