At the October 6th meeting, the Committee charged with dissecting and debating formation of new payment reform strategies in Massachusetts raised as many questions as it answered. One of the bigger areas for today’s debate: the degree of prescriptiveness or flexibility of authorizing statutory language. While there was general agreement among business leaders and trade associations for large provider groups (hospitals and doctors, in particular) that flexibility be the goal, there was some concern that too much flexibility might dilute the reform’s key provision: Accountability. (“If we don’t spell out who is accountable for what and too whom, we risk having none,” was how one participant put it.) Home health and behavioral health providers were united in expressing concern that too much “flexibility” could undermine access to essential “downstream” services in the interest of cost savings.
Other questions debated without little resolution: what is the relationship to be between ACOs and insurers? Can models exists with very different levels of integration (full vs virtual, of payment (fully bundled, partially for only certain services)? How prescriptive should oversight be on collecting and reporting of quality data? The idea of allowing – at least initially – many models had significant (although not universal support), including the Alliance’s. There was at least one expressed opinion that virtually integrated ACOs could simply mimic the fee for service system that the state is committed to moving away from. This was somewhat countered by the support for transparency and shared “performance risk” across collaborating entities that has been shown in some demonstrations, such as STAAR, can begin to improve outcomes. HHS Secretary Judy Ann Bigby indicated support for tiers of integration that could be seen as “stages of payment reform development” with an oversight Board assessing how various models are working and then changing incentives to move system towards the most effective.
As to the apropos unicorn analogy, it came from Mass Hospital Association VP Jim Fitzpatrick. Fitzpatrick quipped that ACOs were like unicorns in that no one has ever really seen one locally, but we all seem to know what they look like. Indeed!