by Alfred Gilchrist, CEO Colorado Medical Society

Alfred Gilchrist

After nearly 50 stabs by the U.S. House of Representatives at repealing the Affordable Care Act and the second Supreme Court ruling to sustain this still divisive body of law, the coverage debate is once again settled for the time being and Colorado’s hard work in the real world of care delivery and payment reform continues.

Health policy leaders in Colorado, who probably gave the recent ruling confirming federal premium subsidies for federally-run exchanges not more than a glance, are back at their desks and negotiating tables. Their focus continues to be on making the ACA work for patients and providers – seeking program and cost efficiencies, new delivery models, and patient education about health plan charges, payments and networks.

Make no mistake, cost is in the crosshairs, and the transition of linking payments to quality measures embedded in the bipartisan H.R. 2 (the SGR repeal and replace), state government-based initiatives, and Colorado’s competitive insurance marketplace dynamics (see cover story on page 8), are more immediately relevant. While most of Colorado’s delivery system leaders and innovators already understand these dynamics, not everyone may be up to speed or shovel-ready.

On the public policy front, the challenge is determining rational state policy on how networks are formed, maintained, trimmed or expanded, and how prices should be determined, disclosed or possibly arbitrated when the services are out-of-network. These issues are at the heart of the transparency discussion and we aren’t talking about a white paper exercise. Both sides of the aisle and multiple stakeholders are actively engaged.

Sen. Tim Neville (R-Littleton), speaking in June to our recently appointed, multi-specialty Work Group on Managed Care, promoted as a starting point “plain English” price disclosures for the most common services, and building out from there in future years. The senator supports market-based solutions to bending the cost curve and emphasizes that some rational level of transparency is needed or the default is “government only,” to use his words. Sen. Neville also notes that he prefers to have physicians fix the disclosure issue rather than default to a “fix” crafted by the state legislature.

Neville’s philosophical opposite and Senate colleague, Irene Aguilar, MD (D-Denver), advocates protecting consumers from surprise out-of-network medical bills and excessive charges without harming providers who are operating ethically. These concepts are simple to explain and difficult to operationalize.

Both senators operate from a common denominator – consumers have a right to know the cost before they purchase when and if possible. Both senators fortunately acknowledge that these policy shifts are complicated and will require a soft landing, perhaps a transitional period to allow market stakeholders to adjust and refit their business plans and operations. Our starting point is to understand that this public policy debate is not in the abstract, or in some distant convening of the General Assembly. These policy options are being developed right now.

CMS surveys continue to reveal payer issues a close second in importance only to maintaining the state’s relatively stable liability climate. During the month of July, we’ll poll our members to get an even better understanding of physician-payer marketplace dynamics. The data will be shared with public officials and with our friends representing the insurance industry. It will enhance our evidence-driven approach to public policy (see related Q&A with Peter Ricci, MD, on page 14) and ensure that we bring ideas to the table that have long-term, positive consequences for you and your patients.


Categories: Communications, Colorado Medicine