Today's story begins in the Massachusetts State House Senate chamber.  Prominent in the chamber is the Holy Mackarel.  (Really.  The House chamber is graced by the Sacred Cod of Massachusetts; the Senate had to get something.)

A recent alum of the Massachusetts Senate, one Scott Brown, has been eliciting cries of Holy Mackarel (and worse) this week.  The stunning setback to health reform represented by Brown's election to Ted Kennedy's seat the people's seat in the US Senate is just sinking in — inside the Beltway, across Massachusetts, and around the country.  While we all try to figure out what brand of libertarian/conservative/republican Brown really is (he's already disavowed some of his campaign rhetoric as just that, and he did vote for health reform as one of the very few Republican state senators in Massachusetts), and Congressional leadership and the White House go into a tizzy figuring out what Health Reform Redux is going to look like, a number of wise men (and women) have been prognosticating about what a politically viable bill might look like Health Reform Redux — see, e.g., the recent posts by Kevin Pho and Ken Thorpe.

The now-likely-dead health reform bills are classic political sausage; my fave commentary on this point this week was the neologism, "the Nebraska Purchase."  In the end, nobody was happy with the outcome — the bills are too socialist for the gummint-outta-my-Medicare crowd, and too conservative for the idealistic progressives among us.  Given the enormity of this setback, and the likelihood that any gains to be made legislatively this session are going to be far more incremental even than those in the recent bills, it is time to think about other avenues towards the improvement of the health care system in this country.

The federales control most of the dollars that flow through the medical-industrial complex; however, with or without a federal health reform statute, there are several paths forward to improving health care in this country along the parameters of access, cost and quality — the famous three-legged stool of health reform. The laboratories of the states, CMS demos and pilots, and initiatives that may be undertaken without the blessing of the federales or state governments (e.g., patient-centered medical home (PCMH) pilots initiated by large — and often self-insured — employers) are fertile ground for experimentation.

Here are some of the changes that I would like to see, without waiting for that promised summer blockbuster, coming soon, Health Re-Reform, the Sequel:

I would hope that CMS would be as liberal as possible in rolling out demos that build on some of the demos to date (and perhaps Congress could authorize some broader demo authority for CMS to tinker with while the Sequel is in production).  I'd like to see more pay for performance and value-based purchasing, including gainsharing, global payments and more.

While some (e.g., Jeff Goldsmith) believe that we've already bent the cost curve, others (e.g., Jacob Hacker) seem to think that the federales have done pretty well for themselves on the bending-the-cost-curve front for the Medicare population, and that the lessons learned can be applied to other populations.

I expect that private employers will continue to expand PCMH programs, given the positive response from employees, and the significant ROI realized through implementation of these programs, including management of chronic disease.  The trick in this arena will be expanding PCMH programs beyond big employer-big network partnerships, so that smaller providers may be able to participate on an equal footing.

Which brings me to the states — our laboratories.  State-level PCMH demos that provide a la carte services (including innovations like the "timesharing" of nurse case managers) to small physician practices that need them in order to participate in PCMH plans ought to become more widespread.  Again, the ROI is there, so the investments should be made by the states.  Other supports for primary care, prevention and public health should be explored, since well-conceived and well-executed programs can have a significant ROI as well.

All in all, it seems to me that there are opportunities to address the access, cost and quality issues without waiting for broad legislative action. 

What do you think?

David Harlow
The Harlow Group LLC
Health Care Law and Consulting