But those inevitable adjustments should not obscure Baucus' achievement
in creating what could be a fiscally durable framework for expanding
coverage while simultaneously reforming the medical system. The bill
represents by far the most serious effort to implement the innovative
thinking from the community of health care reformers looking to move
the medical system away from today's fee-for-service model toward a
system that ties payments to providers to results for patients. It
contains about a dozen major ideas-most of them implemented as national
programs under Medicare, not merely as pilot projects-to nudge the
medical system toward adopting the integrated models used by
institutions such as the Cleveland and Mayo clinics and the Geisinger
Health System to deliver high quality care at lower cost.
"You are not going to replicate Geisinger everywhere, but you can
replicate their functions and that's what this bill is doing," says
Kenneth Thorpe, chairman of the health policy department at Emory
University's Rollins School of Public Health. "They are building many
of the same payment and incentive models that you see in these
integrated practices that have been very effective."
Mark McClellan, director of the Brookings Institution's Engelberg
Center for Health Care Reform, and the former Medicare and Medicaid
director under President Bush, was similarly impressed. While the
Baucus proposal didn't move as boldly as McClellan would prefer on some
fronts-like reforming medical liability laws-he said the plan
substantially tracked the recommendations of a widely-praised
bipartisan report that he recently released outlining strategies to
slow long-term spending growth. "It does bend the [cost] curve in the
long term," McClellan said. "They clearly are working hard to make
fiscally responsible decisions about health care reform."
The senior administration official agreed, giving the plan an overall
"a-minus" grade for structural long-term reform. "The big things are
all there," said the official. "Maybe the reason it's only an "a-minus"
is they are not always there full blown. But it is the legislative
process, and along these dimensions, it is about as good as one is
going to find in a real proposal."
The Baucus bill incorporates most of the
major ideas that reformers have offered to encourage long-term
cost-savings in the medical system. Two common themes link these ideas:
shifting the reimbursement model away from volume to value, and
encouraging physicians to work more closely in teams to manage the
overall health of patients, particularly those with expensive chronic
conditions. The bill would implement these ideas within Medicare,
though advocates hope that if these practices prove effective, private
insurers will adopt hem as well.
One set of proposals would reward Medicare providers who deliver care
more efficiently and penalize those who don't. Starting in 2013, the
bill imposes payment penalties on hospitals who readmit too many
patients for preventable reasons after treatment. It imposes more
modest penalties on hospitals whose patients acquire the most
infections within the hospital itself. Another proposal addresses the
concerns popularized by surgeon and New Yorker writer Atul Gawande on
the vast divergence between spending on medical services in different
communities: that provision would compare the amount all physicians
spend on patients with similar conditions, and starting in 2015 cut
Medicare reimbursements by five per cent for those who order up the
most care. Hospitals would receive similar treatment. Today's law
requires hospitals to record whether they meet a list of quality
measures, like providing aspirin to heart patients. The Baucus bill,
for the first time, would link their reimbursements to their actual
performance on those measures.