Comments on: Payment Reform Should Drive Delivery System Reform

By: Bob Stone

Bob Stone — Fri, 08 May 2009 14:06:13 +0000

Since our historical track record with respect to payment reform leading to system reform falls somewhere between abysmal and poor, I am disheartened to see it, once again, emerge as “the solution” to all that ails our health care non-system.

Continued focus on issues that relate to how the system works and is paid for doesn’t constitute reform…improvement, perhaps… but reform no.

As Deming reminds us a system must have an aim, a purpose, what Eisenhower called the single overriding objective to which all other considerations must bend. Absent such an aim, there is no system.

And absent such an aim, no amount of tinkering with coverage, payment, facility or manpower policies is going to result in a system.

By: François de Brantes

François de Brantes — Tue, 05 May 2009 15:10:03 +0000

If payment reform works, then new organizations that can respond well to the incentives will emerge. As in many industries, the focus on producing high value results pushes towards some level of consolidation, but that consolidation is done to increase the value offered. As reform sets in, there might be a trend by some larger organizations to buy up smaller ones that seem to be effective as a means to spread within the larger organization the more dynamic culture of the smaller one. However, those combinations have rarely been successful.

By: Health Care. (united health care, universal health care) » Blog Archive » Health Affairs Blog Top 10 Posts For April

Mon, 04 May 2009 22:31:04 +0000

[...] Payment Reform Should Drive Delivery System Reform by Francois de Brantes and Lawton Burns [...]

By: RogerCollier

RogerCollier — Mon, 27 Apr 2009 23:49:47 +0000

There are strong arguments to be made for bundled health care payments — especially in terms of improving coordination among various providers. In fact, these arguments seem to be strong enough that we should move forward immediately with major demonstrations — but ONLY within the IDS context. Medicare’s precarious finances (and their bureaucratic process for pilots) do not leave us with the luxury of wholesale testing of “the boundaries of these organizations in pilots before deciding what those boundaries should be.”

Also, it is unclear what studies the authors had in mind when they stated “industrialized countries…consistently produce better results, partially because they are focused on implementing the right processes of care and have let care delivery organizations emerge naturally as a result of the payment incentives.”

Other OECD nations produce better results for three main reasons: (1) They have universal coverage and so avoid having large sub-populations with inadequate care; (2) They place far greater emphasis on both public health and primary care; (3) Specialists are more likely to be on the staffs of hospitals — in effect, resulting in bundled payments and better care coordination.

If the authors intended “better results” to mean more cost-effective results, an additional reason should be considered: (4) Most other nations tightly control hospital resource expenditures and physician incomes are lower than in the USA.

By: Kaiser Daily Health Policy Report Feature Highlights Recent Blog Entries « Eclectic Buzz Blog

Tue, 21 Apr 2009 19:44:26 +0000

[...] de Brantes and Lawton Burns on the Health Affairs Blog argue that changes to provider and hospital payment systems “must drive changes in the [...]

By: Health Care. (united health care, universal health care) » Blog Archive » Female Undies and Integrated Delivery Systems: The DMCB Examines the Relationship

Tue, 21 Apr 2009 12:00:27 +0000

[...] there are a few contrarian souls out there. The DMCB really likes this piece written by Francois de Brantes and Lawton Burns over at the erudite Health Affairs Blog. Noting [...]

By: maryhall26

maryhall26 — Mon, 20 Apr 2009 22:56:22 +0000

“Vertically integrated structures are notorious for being inflexible, bureaucratic, internally divisive, and slow to change- the opposite of what we are trying to achieve.”
Integrated delivery systems are expensive. As a result of the expense, many have undertaken a sizable debt which negatively affects competitive positions. Vertically integrated systems also create large health care entities that are less responsive to market needs. Although with high costs incurred with growth, a large system may not feel the need to change. A new payment model may create incentives for small and medium-sized practices to change over larger practices. Can you see larger organizations taking over smaller ones if the change is made and not proved to be beneficial? Would this make the current problem worse?

By: Payment Reform Should Drive Delivery System Reform « Ilovebenefits’s Blog

Sun, 19 Apr 2009 02:13:16 +0000

[...] We believe that the commonality among these approaches — their reliance on IDNs, PHOs, and forced hospital-physician relationships (HPRs) as a prerequisite to payment reform — is also their major weakness. To be sure, the two biggest buckets of health care expenditures (nearly 50 percent) are hospitals and physicians, so it makes sense to concentrate on these two sets of providers to achieve cost-containment and quality objectives. However, the organizational models developed to date by these two sets of providers have been weighed in the balance of academic research and been found seriously wanting, perhaps because they have risen mainly to optimize gain in a currently flawed payment system. As one of us argued seven years ago, these models have been preoccupied with the structure of health care delivery (for example, vertical or virtual integration) rather than the process of health care delivery (for example, coordination, teamwork, learning). As such, making payment reform contingent on this type of delivery system “reform” seems inconsistent with the evidence to date. Read the rest of this entry » [...]