Why I Have Hope - Payment reform, team based care, and increasing consumer organization involvement.

I used to do occupational health for a shoe manufacturer in Maine. When I first started I noticed there were about 15 molders and 6 inspectors in the room where they molded the leather uppers to the last (shape of your foot). As I became familiar with the operation, I realized the molders were all paid on the “piece-work” system. They were paid for the number of units produced regardless of quality. The plant needed all the inspectors to fix the mistakes. It was hard for me to believe this was occurring. When I asked about this process I was told “We’ve always done it this way”. Eventually the company realized the problems and changed the payment system. Quality went way up, and they needed many fewer inspectors.

Quality in Health Care

Payment Reform

I am not sure health care reimbursement has been different from paying for piecework, until now. With the Centers for Medicare and Medicaid Services (CMS) announcing its aggressive move away from paying from volume to paying for value (https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html) , and many private health plans following suit (http://innovation.cms.gov/initiatives/Health-Care-Payment-Learning-and-Action-Network/) , I have hope for improved quality. This hope assumes that what gets paid for reflects true beneficial results for patients and consumers. Consumer organizations can provide a lot of guidance for this, especially if they team up with progressive employers/health plan sponsors.

Team Care

Health care used to be defined (and paid for) with the solo doctor working with maybe an assistant providing care. Fast forward to today’s innovative practices, and we have teams of doctors, nurses, social workers, nutritionists, medical assistants, and others working together to provide coordinated care in new models like “Patient Centered Medical Homes” and “Accountable Care Organizations”. (http://www.mainequalitycounts.org/page/2-659/patient-centered-medical-home )

This gives me real hope. However, old models die hard. Power and control can get in the way. Consumer involvement in helping shape this new delivery system will be vitally important.

Role of Consumer Groups

While there have always been consumer organizations involved in some aspects of quality of care, there are now many more playing vital roles. As a consumer organization decides how they might effect change, they could consider three different pathways.

Pathway to Change 1: Legislative/regulatory/task force advocacy. Perhaps one of the more traditional pathways, this inserts the consumer voice in the development of laws and rules and in the many task forces that are forming to help guide the rapid evolution of our health care system. With the State Innovation Model awards to 26 states by CMS, advocacy groups are gearing up to support consumers involved in their development: (http://familiesusa.org/blog/2015/09/advocate-participation-state-innovation-model-sim-grants). While advocacy has always been important, with the abundance of change occurring at the national and state levels, it is more important than ever. You can be assured that thousands of educated, smart, and capable providers are intimately involved in all these efforts.

Pathway to Change 2: Consumers as purchasers/external change agents. Labor groups involved in purchasing health care for their members have become instrumental in driving positive change in the health care system. We have had terrific experience with this in Maine. (http://forces4quality.org/maine-labor-management-groups-drive-delivery-system-redesign). In addition, other groups are active in various states, with one of the longest serving and most effective in Massachusetts (http://www.mass.gov/anf/employee-insurance-and-retirement-benefits/oversight-agencies/gic/). It takes a lot of time and effort to engage groups and help them become effective, but the results can be significant in improving the quality and costs of care over time.

Pathway to Change 3: Consumers as internal change agents. Perhaps the newest, hardest, and mostly still untapped change agents are consumers involved on boards or advisory groups in various sectors of the health care system. With the catalyst of the Accountable Care Act (ACA) and the long time advocacy of groups like the Institute for Patient and Family Centered Care (www.IPFCC.org) and others, more consumers are being recruited to work on Patient Family Advisory Groups, task forces, and work groups in hospitals, physician practices, mental health agencies, home health agencies, etc. Now many more consumer organizations focus on supporting effective involvement and internal advocacy in these various efforts.

I have real hope that consumers, working with others who give, get, and pay for care, can have a positive effect on the changing health care system. With the help of the Robert Wood Johnson Foundation, Consumers Union has established the Health Care Value Hub (http://www.healthcarevaluehub.org/) to provide valuable support to health care advocates around the country. Another supportive group, Community Catalyst, has produced a terrific document on how consumers can help on the Path to A People Centered Health System (http://www.communitycatalyst.org/resources/publications/the-path-to-a-people-centered-health-system-next-generation-consumer-health-advocacy ) and are working with consumer organizations in different communities to drive change (http://www.communitycatalyst.org/initiatives-and-issues/initiatives/value-advocacy-project).

All these efforts give me real hope. My kids and grandkids are depending on it.