BoC Topic
Organization/Individual Rational/discussion
NOT
“Comprehensive
Care”
Noel R. Peterson, M.D.
President, Minnesota Medical
Association
On behalf of the Minnesota Medical Association
(MMA), I am writing in response to the invitation to
submit, by January 7, topics for discussion by the
Baskets of Care Steering Committee. The MMA
believes very strongly that the Steering Committee
should not select "comprehensive care" (i.e., total,
comprehensive care for all conditions of an
individual) as one of the seven baskets. A
comprehensive care basket would result in nothing
more than a shift to a fully capitated arrangement
for all services that would inappropriately subject
physicians and other providers of care to managing
insurance risk. The MMA submits that the intent of
the baskets of care provision was intended to be
more limited, given that the Legislature abandoned
the "Level 3/total cost of care" concept in favor of a
voluntary and limited basket of care model.
The MMA believes that conditions selected should
facilitate innovation in the delivery of care for such
conditions; should encourage greater coordination
of care; should support efforts to develop
continuous healing relationships between a care
team and a patient; should be measurable (i.e.,
clinical outcomes); and, should be easily understood
by patients, providers, and payers.
The MMA is pleased to be participating on the
Steering Committee (via representatives Dr. David
Estrin and Dr. Michael Tedford) and is committed
to the pursuit of meaningful payment reform in
order to accomplish comprehensive reform of our
health care system.
The MMA is optimistic that the baskets of care
provision will provide Minnesota with a means to
encourage greater innovation and efficiency in care
delivery. In addition, baskets of care offer the
potential to study and investigate alternatives to the
volume-driven incentives inherent in fee-for-service
payment methods. That being said, there are
numerous and complicated issues and questions that
must be addressed before baskets of care are
implemented. The MMA looks forward to working
with other members of the Steering committee to
make baskets of care a successful endeavor.
Thank you for your consideration.
Process of
Advance Care
Planning
Northwestern
Health Sciences
University and the
Minnesota
Chiropractic
Association
• Coronary
artery bypass
graft (CABG)
• Percutanerous
transluminal
coronary
angioplasty
(PTCA) with
stents
• Aortic or
mitral valve
replacement
• Hip
replacement
• Knee
replacement
• Lumbar spine
fusion
• OB - allow a
package for
normal
delivery and
one for Csection.
Duration
could be a
year and
include all
prenatal care,
delivery, and
post natal
Sue A. Schettle
Chief Executive Officer
East Metro Medical Society
I recommend that the process of advance care
planning be considered as one of the baskets of care
because of its impact on the healthcare system as it
relates to increasing the quality of care, decreasing
cost, respecting the wishes of patients, making sure
that providers have all of the information necessary
to make treatment decisions, and increasing the
understanding and awareness of patients wishes for
their families who are often times left with trying to
make emotional decisions.
Trisha A. Stark, Ph.D., LP
Director of Professional
Affairs
Minnesota Psychological
Association
Charles E. Sawyer, DC
Senior Vice President
Northwestern Health Sciences
University
Refer to attachment A
Jennifer Furan
Policy Counsel
Blue Cross and Blue Shield of
Minnesota
To begin, baskets of care should focus on
developing baskets for acute care episodes.
Generally, a patient with chronic illness does not
just have a single chronic illness for which the
necessary services can be neatly packaged into a
single one-size fits all basket of care. Building
baskets of care around chronic conditions that have
wildly varying health care needs from one period to
another and which may have multiple comorbidities, would likely result in providers needing
to build so much "variation cushion" into basket
pricing that it would likely result in increased costs.
An alternative could be to greatly limit the contents
contained in a basket, but that would defeat the
original intent of baskets of care. Further, the
assumption that these chronic conditions lend
themselves to one year "baskets" is not realistic with
regard to how a patient accesses care or how
insurance is purchased and accessed. But if
Minnesota begins with acute care episodes,
beginning with high volume/high cost episodes that
have a defined beginning and end-point, then this
would allow the entire health care system to learn
Refer to attachment B
how to make baskets of care work.
follow-up.
•
•
•
•
Preventive
Care
(inclusive)
Well Child
Care
OB care
Depression
Virginia Barzan, C.A.E.
Executive Vice President
Minnesota Academy of
Family Physicians
John Tschida | Vice President,
Public Affairs & Research
Courage Center
Refer to attachment C
Thomas G. Patnoe, M.D.
President/Chief Medical
Officer
SMDC
The Health Care Reform Legislation requires the
development of baskets of care for seven health
conditions. Four were specifically mentioned: heart
disease, diabetes, depression and asthma.
Depression and Asthma are often isolated
conditions, provider organizations could calculate a
basket of care price.
Heart Disease and Diabetes, typically involve other
co-morbidities making it more difficult to calculate
a basket price. Providers may be reluctant to set a
basket price for these conditions given the
unpredictability of the condition.
Possible solutions for this could be:
Include only those patients with a single diagnosis
of heart disease or diabetes (type 1 and type 2 would
need separately priced baskets), i.e., without comorbidities.
Establish an outlier threshold, whereby if a patient
incurred a certain dollar amount of charges, the
provider would be paid on the regular fee for service
methodology.
Potential other health conditions that could be
basket priced:
Low Back Pain - This condition is frequently
mentioned by employer groups as a common, high
cost, high rate of absenteeism.
Joint Disease - This would encourage providers to
manage high tech imaging services and well as find
alternative, more cost effective treatment than joint
replacement surgery.
Additional conditions that may qualify for basket
pricing include Pregnancy (C-sections/ or
uncomplicated Vaginal delivery) and
Hysterectomies.
Other considerations in connection with basket
payments to providers include:
Managing the basket price payments, i.e., monthly
or annual payment to care system
Attributing patient to care system, for basket
pricing;
Providers must have the opportunity to "disenroll" a
patient out of a basket priced program due to noncompliance, change of care system or patients
visiting multiple care systems;
Conditions outside of the basket condition, must
continue to have fee for service payments to the
providers;
Drug costs should be carved out of basket price,
pharmacy prices are controlled by the health plans
and providers are typically unaware of these prices.
The Centers for Medicare and Medicaid Services
recently introduced an Acute Care Episode (ACE)
Demonstration Project centering on bundled
(basket) payments. The concept is similar to the
State's Basket of Care reform initiative, though
centering on acute episodes. Providers participating
in the demonstration submit bids for conditions
focusing around cardiac and orthopedic care. SMDC
Health System encourages the Baskets of Care
Steering Committee to review information on this
project, as some aspect may apply.
Preventive Care
Tom Kottke - HP
I think that this is a great opportunity to make one of
those baskets preventive care and, conversely, if one
of those baskets is not preventive care, we will be
missing a great opportunity to improve the health
status and health stock of the community, thereby
avoiding future costs of chronic disease..
Waiting for acute episodes to develop simply will
not suffice. Figuratively speaking, "we cannot get
there from here" by focusing on acute exacerbations
of chronic diseases. For example, our calculations
in the attached publication indicate that perfecting
care for acute cardiac events can prevent or
postpone no more than 8% of all deaths. The
implementation of effective programs to prevent
chronic disease risk factors--mostly through
improved nutrition, adequate physical activity, and
elimination of tobacco--could prevent or postpone
up to 33% of all deaths. Implementation of
effective secondary prevention programs could
prevent or postpone another 23% of all deaths. The
bottom line is 8% vs. 56%.
The scope of intervention can be controlled by
HealthPartners
Consumer Worker Coalition
Jim Hansen
defining "preventive care" on the basis of the ICSI
Preventive Services guideline and the ICSI
Prevention of Chronic Disease Risk Factors
guideline. While clinical preventive services would
be delivered in the clinical setting with the usual
mechanisms of compensation, the interventions
related to the ICSI Prevention of Chronic Disease
Risk Factors guideline--interventions related to
nutrition, physical activity, smoking, and risky
drinking--should be delivered through delivery
channels of known efficacy. The HealthPartners
example is JourneyWell; other programs are also
effective. Defining lifestyle counseling services in
this way would avoid the problem of needing to
compensate physicians for "counseling, NOS".
Refer to attachment D
Refer to attachment E