MMA Viewpoint
Proceed with Caution in Developing Baskets of Care
The 2008 health care reform legislation directed the Minnesota Department of Health to develop at least seven “baskets of care”—defined services associated with the treatment of certain conditions—that clinics and systems may choose to offer at a fixed price after January 1, 2010. The MMA is actively involved in the process to make sure that we avoid potential pitfalls.
The baskets-of-care concept arose from concern that the fee-for-service payment system rewards more care, rather than the right mix of care. Sometimes providers lose money for doing the right thing. For example, patients with congestive heart failure (CHF) whose care is well-managed have far fewer hospitalizations and lead less-restricted lives than those whose care is poorly managed. Proper care may even delay or prevent death from heart failure. Perversely, under the fee-for-service model, practices that are especially good at managing patients with CHF may receive lower revenues for that care. At its best, the baskets-of-care model seeks to reward the right mix of care for the patient, rather than the most care.
The Baskets of Care Steering Committee has decided to create baskets for treatment of diabetes without comorbidities other than hypertension and hyperlipidemia, preventive care for children, preventive care for adults, asthma care for children, obstetrical care, total knee replacement, and treatment of low back pain. Committees are currently wrestling with the definition and structure of each basket. David Estrin, M.D., and Michael Tedford, M.D., represent the MMA on the Baskets of Care Steering Committee, and 15 other MMA physicians are serving on the seven subcommittees. They will submit their recommendations to the Commissioner of Health by May.
We realize the baskets-of-care concept has the potential for negative consequences. For instance, it could create an incentive to withhold care in order to maximize revenues. To minimize the chance of that happening, outcomes will need to be reported and evaluated. If the baskets-of-care approach is used only to reduce cost, the MMA will not support it.
The approach has the potential to undermine the health care home concept. If patients choose one system for diabetes care and another for their low back pain, it would defeat the promise of the health care home to provide ongoing, coordinated care. The MMA strongly believes that the baskets should support, not undermine, the health care home. We also believe that the baskets should be structured in such a manner that large systems do not have an inherent and insurmountable advantage over smaller, nonintegrated clinics. The MMA will not support the development of a basket for the comprehensive care of an individual that would hold physicians and other health care providers responsible for the cost of all of their health care.
How should we proceed? In a word—cautiously. The MMA supports exploration of alternative payment approaches that support quality care and encourage innovation in care delivery. We support efforts to reward physicians and systems that provide better value. Improving patient outcomes while lowering cost produces the greatest increase in health care value. Baskets of care may be a means to that end. But caution is needed at each step of the way to make the goal of improved reimbursement for better outcomes a reality.