As the House and Senate get close to releasing their versions of comprehensive payment and delivery reform legislation, the Campaign For Better Care, with the help of students from the Harvard School of Public Health, will be doing a series of blog posts this week highlighting our 10 Principles for Better Care.
1. Patient-Centered Care: Payment reform legislation should align incentives so that patients are at the center of our health care system. The payment system should support teams that can deliver culturally-competent, coordinated preventive and primary care that focuses on the patient’s physical and behavioral health. The system should encourage development of a robust primary care workforce.
A patient-centered health care system orients the health care system around the needs of the patient, not the provider, insurer or payer. Making the patient the hub of health care payment allows practitioners to better understand the context within which they are providing care, leading to better health outcomes.
- Require payment levels to be tied to patient outcomes. Quality-linked payments should not be based solely on process measures (like, did the hospital give a patient an aspirin after a heart attack), which are weak indicators and do not correlate well with overall quality of care. Payment should be based on patient outcomes, which will encourage hospitals and doctors to focus on the patient’s needs, rather than the measuring stick.
- Payment should be reduced to providers with higher rates of potentially preventable events, like preventable readmissions or preventable complications. Under the fee for service approach, doctors and hospitals face little or no incentive to reduce complications or readmissions. This crucial policy can be implemented immediately, and need not wait for global or bundled payments. Already, Maryland and New York are implementing this, and Texas and several other states are in process (details). MassHealth has begun to cut rates slightly to hospitals with higher than average readmission rates. The statute should require this approach to be followed universally in Massachusetts.
- Payers should be required to pay for coordination, wellness and prevention services that are currently not traditionally reimbursed, including: care coordination, group visits, home visits, peer support, transportation to and from medical services, culturally appropriate linguistic capacity, patient education and outreach provided by community health workers and others, the implementation of end of life decision supports, shared decision-making, patient transitions support, and preventive and ongoing care for occupational health and hazard issues. Mental health and substance abuse services is a particular concern. Comprehensive care includes recovery coaching and peer navigators.
- Require checklists to be used in hospitals for procedures and activities where evidence has demonstrated quality and patient outcome improvements with their use. Despite being shown to reduce complications and errors, checklists are still not widely used. The Public Health Committee has approved legislation that includes checklists.
- Prohibit copays (and other cost-sharing) for cost-effective drugs, devices and preventive care. The ACA moved policy in this direction by prohibiting cost-sharing for some preventive diagnostic services. This should be expanded to encompass a broader range of care, particularly for those with chronic disease.
Don Berwick, our former Centers for Medicare and Medicaid Services Director sees patient-centered care as “the experience (to the extent the informed, individual patient desires it) of transparency, individualization, recognition, respect, dignity, and choice in all matters, without exception, related to one’s person, circumstances, and relationships in health care.” He sums up the call with three maxims: (1) The needs of the patient come first; (2) Nothing about me without me; and (3) Every patient is the only patient. We say yes, yes and yes.
Better care means patient centered care.