If you have "no place to go," come here!

Are you sure you want to be covered by the public option?


You may get the chance to be a guinea pig for those "cost-cutting" and "prevention and wellness" payment "innovations" the technocrats are so eager to try out on somebody [else].

Subtitle B—Public Health Insurance Option



  • (a) IN GENERAL.—For plan years beginning with Y1, 25 the Secretary may utilize innovative payment mechanisms and policies to determine payments for items and services under the public health insurance option. The payment mechanisms and policies under this section may include patient-centered medical home and other care management payments, accountable care organizations, value-based purchasing, bundling of services, differential payment rates, performance or utilization based payments, partial capitation, and direct contracting with providers.
  • (b) REQUIREMENTS FOR INNOVATIVE PAYMENTS.—The Secretary shall design and implement the payment mechanisms and policies under this section in a manner that—
    • (1) seeks to—
      • (A) improve health outcomes;
      • (B) reduce health disparities (including racial, ethnic, and other disparities);
      • (C) provide efficient and affordable care;
      • (D) address geographic variation in the provision of health services; or
      • (E) prevent or manage chronic illness; and
    • (2) promotes care that is integrated, patient-centered, quality, and efficient.
  • (c) ENCOURAGING THE USE OF HIGH VALUE SERVICES.—To the extent allowed by the benefit standards applied to all Exchange-participating health benefits plans, the public health insurance option may modify cost-sharing and payment rates to encourage the use of services that promote health and value.
  • (d) PROMOTION OF DELIVERY SYSTEM REFORM.—The Secretary shall monitor and evaluate the progress of payment and delivery system reforms under this Act and shall seek to implement such reforms subject to the following:
    • (1) To the extent that the Secretary finds a payment and delivery system reform successful in improving quality and reducing costs, the Secretary shall implement such reform on as large a geographic scale as practical and economical.
    • (2) The Secretary may delay the implementation of such a reform in geographic areas in which such implementation would place the public health insurance option at a competitive disadvantage.
    • (3) The Secretary may prioritize implementation of such a reform in high cost geographic areas or otherwise in order to reduce total program costs or to promote high value care.
  • (e) NON-UNIFORMITY PERMITTED.—Nothing in this subtitle shall prevent the Secretary from varying payments based on different payment structure models (such as accountable care organizations and medical homes) under the public health insurance option for different geographic areas.

The public health insurance option may modify cost-sharing and payment rates to encourage the use of services that promote health and value?

This sounds like Nudge territory. Presumably your co-pays or other cost sharing would be lowered if you're fat and agree to join a weight-loss program, or you're a smoker and agree to join a smoking cessation program, but the language leaves it open to your co-pays being raised if you refuse to engage in healthier behaviors.

Then again, aren't there studies that suggest that people who live long healthy lives end up being just as expensive as people who die young from their unhealthy behaviors? Shouldn't we consider taxing the non-smoking, bicycle-riding vegans instead? A nation full of healthy active centenarians is either going to be taking away jobs from the younger folks or bankrupting Social Security.

Accountable care organizations? Darling of MedPAC, dreamed up by the Dartmouth Atlas researchers, who study only dead old people and conclude that this is enough information to know what's going on in the entire health care system. Besides, we tried that back in the 90s and dysfunctional as hospitals were in the old days, that was nothing compared to what they have become as a result of that earlier experiment.

Value-based purchasing? If this sound like something only a CEO of GigantoCorp could love, you'd be right. Maybe. But it would take, among other things, a sort of MedPAC on steroids [IMAC, it's not just for old folks after all!] that wouldn't be subject to micromanagment by Congress. These all look like good ideas and who wouldn't want something that's measured on good outcomes, but what if it's more expensive to get some of those better outcomes? After all, seniors in the much-reviled McAllen, Texas area have a lot of CABGs and the Rio Grande Valley could thus perhaps be considered a 'regional center of excellence' could it not?

Patient-centered medical homes? It's a fabulous idea, reminiscent of the old days when you could just call up your family doc on the phone in the middle of the night, or drop by their office as often as you needed, without even an appointment sometimes, and if you were lucky yours made house calls. The updated modern version is aimed at taking care of patients with complex health issues, and the doctor may see you less often, but a nurse or other allied practitioner is available. Do people get better care? Yes. Does it save money? Maybe, maybe not. Who wants to be a patient receiving wonderful care in a program, only to have it discontinued because it costs too much?

Here's a patient-centered experiment we could try: remove the insurance companies entirely, leaving every primary care doctor 4 more hours per week to take care of actual people.

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DCblogger's picture
Submitted by DCblogger on

when you are cheering on Blanche Lincoln and Joe Lieberman.

hipparchia, you are the best researcher in single payer blogosphere.

Submitted by hipparchia on

thanks for the kind words [although most obsessed researcher might be more on target than best].