Once in a while, a key voice in the reform movement turns out to be a skeptic, arguing that the changes being implemented are too prone to producing more of the same.
Take, for instance, Alan Weil, the editor of Health Affairs and former executive director of the National Academy for State Health Policy. "I oppose payment reform," he announced in a speech at the New York State Health Foundation and a follow-up blog post.
"We know fee-for-service leads to fragmentation, it leads to excessive provision of low-value care," Weil says.
But are the myriad pay-for-value initiatives being plied by Medicare, health systems and commercial health insurers likely to really improve the status quo, Weil wonders?
"The core competencies necessary to achieve high quality population health outcomes are different than the core competencies that have been necessary to succeed in the past," Weil points out. "I think it's an open question whether or not those institutions that we built to achieve one set of objectives for the healthcare system will be the ones that are successful at achieving a new set of objectives."
Put another way: "There is no reason to expect that the people and institutions that were successful under the old model are the best people and institutions to charge with carrying out the new model."
Relatedly, the payment reform that the old guard is being tasked with adopting is actually "insufficiently disruptive," Weil argues. "As we capitate or bundle payments, these aggregated payments are generally given to the highest cost actor in the system: the hospital, health plan, or large medical practice that already has the most resources."
In concept, those resources are supposed to be allocated toward lower-cost prevention-focused efforts -- dieticians to work with diabetes, social workers to help those with substance abuse, community health workers to visit people in their homes -- rather than a new surgical wing or neonatal intensive care unit.
"But this may be wishful thinking," Weil argues. "Hospitals and health plans operate with inertia and under constraints that may prevent them from having what an observer might consider a rational response to the new incentives. Marginal changes in payment policy fail to disrupt the concentration of power held by expensive institutions, thereby limiting the likely effects."
The early evidence of some of the most ambitious payment reform programs aren't very promising in terms of addressing the 30 percent of healthcare spending deemed to be wasteful, he continues.
Nineteen of Medicare's original 32 Pioneer ACOs remain in the program, and just welve are producing enough savings to be shared between the health system and the Medicare trust fund, Weil notes. Only 58 of the 200 health systems in the less-advanced Medicare Shared Savings Program are saving more than 2 percent. Neither have produced enough to show that "what we are doing will achieve the end result we desire," Weil contends.
Then there are the end results. "The original rationale offered for payment reform actually doesn't align with the objectives that we're now ascribing to payment reform."
The idea for moving away from fee-for-service came from integrated health systems, like Geisinger, Intermountain and Kaiser Permanente, who told Congress, as Weil paraphrased, "We are trying to do the right thing, we are trying to deliver high quality care, keeping people out of our expensive hospitals and institutions, but every time we achieve that goal, we lose money."
Today, the narrative is different: "We need payment reform to leverage a system that is resistant to change to adopt different models of care, and the payment is the motivation and force to make them do things differently."
The original goal only required an elimination of the disincentive for integrated care to flourish. "Creating an affirmative incentive for those who are resistant to change to fundamentally re-engineer is a much higher level of complexity" that "is subject to gaming" -- like maximizing quality metrics and avoiding complex, at-risk patients.
Weil's last argument against payment reform is that it is not entirely consistent with another movement within health reform, the ultimate reform from the perspective of the collective payers: patient-centered healthcare.
If three people go to a doctor with knee pain -- one who wants to manage pain, one who wants to play tennis again, another who wants be completely pain free -- what kind of "value formula" can providers use, Weil asks? "Even if you could come up with one, operationalizing it would be nearly impossible. And what provider would be willing to accept financial risk for achieving such varied patient goals? When we implement payment for 'value' we oversimplify to make the methods administrable, but lose all nuance of patient preference."
Let leaders lead
Weil is a long-time player in the healthcare policy establishment, a former executive director at Colorado's Department of Health Care Policy and Financing and assistant general counsel in the Massachusetts Department of Medical Security. So, knowing how broken the current system is and all the efforts going into fixing it, he is perhaps an unlikely opponent of healthcare financing reform.
And Weil concedes he is actually not an opponent of payment reform; he just believes the path being taken needs to be different, with a simplified and more grassroots opportunity to evolve.
The end goal of course is multi-payer reform. But you have to "let the leaders lead" before creating multi-payer systems, he argued.
Those have to be "leaders who have enough market clout to move a portion of the market, leaders who are doing this because they want to, with partners who are doing it because they want to, and who are not trying to tackle the whole problem but subdivide it."
"What you need is not technical competency, but agreement on a path that is acceptable based on the values that people bring," Weil says.
Despite ideas that seems somewhat laissez faire, Weil also notes that the government has a big role to play, as the healthcare payer on behalf of taxpayers.
"Payment reform has to be part of a broader strategy that includes, in my mind, defined spending targets and defined policy responses if those targets are not met and explicit initiatives that have goals of reallocating resources away from our healthcare services system to other places that have a bigger effect on health," Weil explains