Wednesday, October 8, 2008

Minneosota, book review - The Road to Reform

Does the road wind up-hill all the way? Yes, to the very end.

Christina Rosetti, Up-Hill, 1830-1894

I’ve always liked the metaphor of a road as the path to the future. Roads wind, twist, and turn. Roads go uphill and downhill. Roads can be blocked, can go nowhere, and you can always go off the shoulder.

One of my favorite books is The Road to Reform? The Future of Health Care in America (The Free Press, 1994). The late Eli Ginzberg, then the dean of health care analysts, wrote it on the eve of President and Hillary Clinton’s failed health reform bill.

The front flap of the book reads,

“Each of the key players is sharply edged, high-earning physicians, the over-bedded hospital sector, employers squeezed by rapid rising benefit costs, inefficient private health insurance companies, highly profitable pharmaceutical and medical supply companies, and, finally, the public who wants more and better care but doesn’t want to pay for it.”

Sound familiar? It should, for satisfying these stakeholders block the road to health reform today. The road to universal coverage is as uphill as it has ever been. We are an incremental, experimental, and conservative nation, which is why we should pay attention to experiments going on in states like Massachusetts and Minnesota. These states are further down the health reform road than most..

I know more about Minnesota than Massachusetts, since I was editor-in-chief of Minnesota Medicine from 1975-1990, and practiced in Minnesota for 25 years. Minnesota has a consensus culture dating back to farmer collectives, and its citizens and its physicians have a reputation for striking compromises for the common good.

These compromises do not always work. The modern managed care movement, which exploded in Minnesota in the early 1970s, hasn’t worked and has had its share of scandals, like the billions of dollars United Health Care CEO William McGuire walked away with after stock option backdating.

But Minnesota still seeks an equitable road to reform. In 2004, the Minnesota Medical Association (MMA) formed a 21 member Health Care Reform Task Force to develop a reform plan. In 2006-2007, the MMA formed Healthy Minnesota: A Partnership for Reform, which has a 26 member steering committee composed of leaders from health care, government, business, labor, education, and patient advocacy groups. These efforts culminated in a law, S.F. 3780, which passed the Minnesota house by 127-7, and the the Senate by 62-5, and which was signed into law on May 29. 1980.

The principle components of the new law are:

1) Medical Homes for coordinating care of complex chronic diseases - The law does not mandate medical homes but encourages patients with chronic disease in public programs to have a medical home. It does not restrict access to specialists, nor does it hold medical homes responsible for all medical expenses. But it sets 2009-2010 deadlines for establishing criteria for certifying medical homes, e.g. having a dedicated care coordinator; for paying medical home practitioners, probably in $50 month per patient range; and for mandating that private health plans have medical homes in their network and for paying plans for care coordinators for patients who choose medical homes.

2) Paying for public health programs for community health boards and tribal governments – These payments, in the form $47 million in grants, will consist of matching grants for projects focusing on obesity and tobacco use.

3) Extending eligibility for insurance coverage to all families with incomes of $60,000 or less – The aim is to expand coverage to 13,000 Minnesota and to encourage 5,000 more to buy insurance on the private market.

4) Institute payment reforms based on pay for performance, peer grouping, baskets of care, and an essential benefit set - The law calls for a standardized statewide system for measuring provider quality and for allowing consumer to compare care. The term “baskets of care” refers to bundles of care or sets of related services with a set price for each bundle, which physicians may establish but may not vary. The baskets, or bundles, of services include – primary care, preventive services, coronary artery and heart disease, diabetes, asthma, depression, and others deemed appropriate.

I have no clue if the Minnesota road to reform will work, or the state will reach its destinations by 2011, the final target date for implementation. But at least, it’s a plan, it’s pragmatic, and it’s agreed upon by major stakeholders.

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