The Milbank Memorial Fund continues the work of helping states in their efforts to transform primary care with its release of a new report Aligning Payers and Practices to Transform Primary Care: A Report from the Multi-State Collaborative.
The report is an observational study of the work of ten states that are members of the Multi-State Collaborative, a voluntary group composed of representatives of state-based, primary care transformation initiatives. The initiatives themselves are collaborations among payers, providers, employers, and state officials. Since 2009 the Milbank Memorial Fund has supported the collective work of these ten states and their initiatives to facilitate learning and progress.
In each of these states, starting in the mid-2000s, private- and public-sector leaders—usually convened by state officials—have organized activities for primary care physicians, payers, and employers based on the following principles:
* Health care cost containment (and therefore affordability) cannot be achieved without delivery system transformation across multiple aligned payers.
* Delivery system transformation is predicated upon access to high-quality primary care and supporting services.
* High-quality primary care is more likely to occur in a formally recognized, patient-centered medical home setting.
* The nurturing of primary care transformation can only be successful in a uniformly applied, multipayer model (involving many different health care payers) coupled with collaborative learning and team-based care.
The report documents challenging work done by the collaboratives in eight areas—ranging from payment reforms to new staffing models to ensuring alignment among providers. The early results vary across states, and most are quite promising. Primary care transformation, clearly a precondition for broader delivery system reform, requires collective action.
The Milbank Memorial Fund, which has a mission to improve the health of populations by connecting leaders and decision makers with the best available evidence and experience, has supported these state initiatives in part because of the evidence documenting the importance of primary care in improving population health—some of it published in the Milbank Quarterly—and the systematic undervaluing of primary care in the dominant fee-for-service payment model. Efforts to act on this evidence deserve support.
The lessons of this work for foundations and policy makers, however, extend beyond the technical details of primary care transformation, such as how incentives should be structured or how practice transformation resources, such as lessons on how best to take on new responsibilities and get more out of electronic health records, should be provided. An underlying question addressed by these efforts is: how does systemic restructuring happen in the health care delivery system?
As a precondition for delivery system reform, the “signals” sent to providers about what we want them to do—what constitutes value—must be consistent. Economists have it right: there is no stronger message than finances—we get what we pay for, and, historically, we have rewarded volume and procedural complexity. No one payer is large enough to send a dominant financial signal by itself. Differing payment reform efforts by multiple payers—Medicare, Medicaid, and private insurers—succeed only in sending conflicting messages to providers and frustrating them.
How to get past this? One theory of change and alignment involves reliance on markets, technology, and consumer choice to drive system improvement. This has given us cheaper smart phones and more efficient financial services. The barriers to that model are, however, legion in health care, including third-party purchase of insurance, comprehensive benefits, and significant imbalances of information between “sellers” (the providers) and “buyers” (the patients).
Another model looks at medical care as a public good. System improvement requires significant public oversight—as in our transportation safety system or education services. Yet these sectors do not have multiple, large private payers outside of direct public control. Nor do they have culturally powerful deliverers of services—as does medical care. Maryland is a notable exception to the rule in that most political climates will not countenance a formally structured all-payer financing model, in which there is a consistent fee schedule, used by all payers, for health products and services.
Given the difficulties of all-payer and consumer-driven models of payment alignment, public officials and other stakeholders are faced with the considerable challenge of trying to achieve consensus on payment standards without the force of law or the power of individual shoppers. The projects documented in our new report strive for the true systemic change required—to build public consensus for system priorities and to align payment and measurement to promote the priorities.
These are exercises in civic leadership and the development and exercise of authority. Who convenes? Who leads? How does one build trust? How is the agenda set? Which conversations are public, and which are private? How is agreement set? How do you address a lack of consensus or a reluctant party? In the absence of the market, or clear governmental authority, leadership is important in setting these norms.
Equally important is the sustainability and durability of any understandings that are reached. Leaders change, and systemic improvements must be self re-enforcing. The ten collaboratives studied in our report continue to work through issues of governance, performance measurement, and financial viability.
This work does not stand alone. Other efforts, such as the Robert Wood Johnson Foundation’s Aligning Forces for Quality initiative, have also explored how systemic improvement actually happens in a multistakeholder environment. The lessons to be drawn from them are not as tidy as “single payer for all” or “create more competition.” They have to do with exercising leadership and authority, building public will and technical competence, and establishing laws and neutral “backbone organizations” to carry out the work. In our federalist model of health care that relies on public- and private-sector financing and mostly private-sector delivery of services, these lessons will have to be learned, documented, and disseminated if the payment alignment required for systemic improvement is to happen.
