Advancing Healthcare Transformation at the State Level

The U.S. healthcare system has the best trained physicians, nurses and other clinicians in the world, and they work very hard, but as I have written many times, they work in a system that is in desperate need of transformative redesign. The payment system has fostered our “traditional” model, which is a bit like a game of Whack-a-Mole, with well-intentioned smart people addressing acute problems as they arise without a commitment to being accountable for improving the individual's health over the long run. The traditional fee-for-service approach means more visits completed and more procedures performed equals more profit. It is a sobering statistic that we spend 40% more per capita on healthcare than any other industrial country, and our outcomes for chronic illness are not as good. And now we have the added problem of medical debt, which has become the biggest single cause of bankruptcy in the United States. 

We know that it is much better for all involved if we build relationships with patients in the primary care setting and remain committed to helping them stay healthy and out of the hospital. Treating patients only when they are sick or seeing them in a hospital setting for preventable issues is not doing them any favors and is costly to the country. 

That is why Maryland implemented “global budgets” within its “All Payer” Model and waiver with the Centers for Medicare and Medicaid Innovation Center. This reimbursement system gives hospitals a fixed amount of revenue each year, encouraging them to reduce unnecessary hospitalizations, procedures, tests, and more. GBMC HealthCare had already committed to holding ourselves accountable for the improved management of chronic disease and for keeping patients out of the hospital, so we quickly accepted the concept of the global budget when it was introduced in 2014. Then, when the voluntary Maryland Primary Care Program (MDPCP) was introduced to support the delivery of advanced primary care throughout the state, we eagerly decided to participate, since this would provide new resources to cover the cost of the patient-centered medical home.  

We have been supporters of the global budget and MDPCP because at their core, they are focused on doing the right thing – being accountable with patients for their health and successfully managing (or preventing) chronic conditions in the outpatient setting. Now, I am intrigued by a new program being introduced by the Centers for Medicare & Medicaid Services (CMS). It is still in its infancy but seems like it could be the next critical step in healthcare transformation towards better value. 

The new program is called the States Advancing All-Payer Health Equity Approaches and Development (AHEAD) Model and aims to work with states in controlling healthcare costs, improving population health, addressing social determinants of health, and promoting health equity. This program involves a voluntary, state-driven approach where states as a whole can apply to participate. This differs from MDPCP because with that program, individual healthcare organizations within the state could decide whether to participate. That meant that transformation was only happening in silos since not all our healthcare institutions within our state were required to embrace this approach to care delivery. The AHEAD Model better marries the concepts of the global budget and MDPCP in a way that would more effectively force transformation uniformly. 

Unless there is a broader scope of adoption of the advanced primary care mindset with a focus on providing accessible and equitable healthcare opportunities to all, the system will remain broken. Medical debt will continue to cause bankruptcy, and many people will continue to not have access to the care they need when they need it, in the most appropriate setting. 

We do not yet know which states will opt for the AHEAD Model. But, if Maryland opts in, I feel confident that GBMC HealthCare is well positioned for success because we have laid so much groundwork over the past decade. I am excited to see how this new program might move the nation toward a better healthcare system.