Payment Reform: 12 Patient Priorities

The passage of the Affordable Care Act creates opportunities for our state and our country to pursue innovative health care payment reform models designed to promote accessible, coordinated, patient-centered care that focuses on health and disease prevention and reduces health care costs. As payment reform models are advanced, a number of critical concerns, particularly for health care consumers, must be addressed by any legislation or other efforts to implement payment reform.

Any payment reform model, including Accountable Care Organizations (ACO) and Medical Homes must incorporate the following principles to ensure that the health and rights of consumers are protected.

1. Transparency: Measures of care and incentives built into the payment system must be open, transparent, and understandable by patients. The legislation should provide for an open process through which there is full disclosure, capacity for public review, and explanation of all payment criteria.

2. Protect Vulnerable Consumers: Payment policies should take into account the higher costs of patients whose needs are affected by high medical utilization, socio-economic status, language and other social/cultural factors. Patients with high medical utilization should be protected by outlier payments.

3. Consumer Voice: There must be a substantial number of consumer representatives on the Board of any Accountable Care Organization (ACO). Any government body that regulates, sets policies, or approves payment plans for ACOs must establish a process in which the public has the opportunity to review and comment.

4. Savings Shared With Consumers: Cost savings must be used by the ACO to expand access and improve the quality of services provided in addition to providing savings to taxpayers.

5. Patient Choice and Care Accessibility: The payment system should ensure patient choice of primary care and other providers such as specialists, nurse practitioners and mental health professionals. Patients must have access to caregivers with linguistic and cultural capacity to provide effective care. Payment systems must promote patients’ continuity of care with their providers. Patients must have access to medically necessary out-of-network care.

6. Improve Quality: Any gain-sharing payments made to an ACO must be based on improved outcomes.

7. Evaluation and Monitoring: The legislation must include independent, meaningful and frequent monitoring and evaluation of the payment system focusing on quality of care, including outcomes, patient satisfaction and quality of life. The evaluation must be public.

8. Patient Empowerment: A number of patient activation and patient empowerment methods have been shown to lead to better health outcomes, reduced disparities, and better satisfaction with one’s health care, as well as reduced costs. Models such as chronic disease self-management, ideal medical practice, shared decision-making, and others must be supported by the payment system employed by the ACO.

9. Promote Public and Community Health: Payment reform must be accompanied by a commitment to fund public and community health initiatives. Any ACO must be inclusive of community based health providers such as health departments, community health clinics, mental health providers and homeless shelters. New resources must be added to current public health spending for payment reform to be successful.

10. Patient –Centered Primary Care: Payment reform legislation should align incentives so that patient-centered primary care is the center of our health care system. The payment system should support teams that can deliver culturally-competent, coordinated preventive and primary care that focuses on the patient’s physical and behavioral health. The system should encourage development of a robust adequate primary care workforce.

11. Care by Appropriate Providers: Care must be provided by the most appropriate caregiver, practicing within their scope of practice and specialty. Health professionals must have workplace rights, whistleblower protection, and serve on committees developing practice models, reviewing outcomes and care management.

12. Patient Driven Motives: Any ACO must be a non-profit entity and all employees of the non-profit must have reasonable salaries.