Payment system redesign will always require finesse, and other letters

Regarding the Jan. 5 editorial “Lessons from Vermont”, perhaps it is too easy to criticize from afar, when being on the inside of such an endeavor comes with all the political and social pressures that make some options untenable, forcing the choices that are less viable economically. It is hard to second-guess.

From the armchair where I sit, I think of the single-payer exercise as a formulation of plan design, funding, access and payment strategies. If the plan design is too rich or too thin at the start, all else is doomed to fail. Funding is tricky, given the taxation model described and the lack of federal buy-in, which is fraught with political potholes.

It sounds as if there was no other access and provider payment strategy other than state-mandated uniform fee-schedule fixing. While there is merit to standardization to reduce administrative waste and hassle factors, this step is like rearranging the deck chairs on the Titanic. Without a more robust plan, the ill-fated fee-for-service ship is eventually going to take on water and sink.

One of the lessons of accountable care models is that the financing of healthcare needs to cascade down to the delivery system to stimulate the alignment of the natural components to work together effectively and efficiently. The vehicle needs to be transparent and accountable for quality and cost, as well as for patient experience. None of this is expected to take off and work nicely like turning on a light switch. It will require a multiyear transformation like nearby Massachusetts.

Kevin Mowll

About the Jan. 5 editorial “Lessons from Vermont”, the demise of Green Mountain Care is attributable to a single factor: the available federal money to prop up this socialized medicine scheme ended up being greatly less ($150 million instead of $267 million) than anticipated by Gov. Peter Shumlin. So, being a “survivor politician,” Shumlin jettisoned the entire plan before it could become a political millstone that might drown him.

Daniel Groszkruger

Regarding “Medicare penalties begin taking toll”, in addition to all the percentages in articles like this, how about some dollar amounts? For example, what does a 4.21% reduction to Pennsylvania Hospital represent? Eventually, less money translates to fewer services. Simple economics.

More troubling is the comment that our safety net hospitals are “operating at a 0.4% loss on average” and facing additional cuts. These cuts have to be offset—and the majority of patients at these safety net hospitals are the poor and vulnerable, who most need these services.

It's another example of unintended consequences when a distant authority relies on sterile numbers.

John Weir

Regarding “Obamacare re-enrollment into lower-cost plans draws objections”, this would be a disaster. Many of the provider networks in the marketplace are so narrow that people would almost surely lose access to their doctors. I am an independent insurance agent, and the biggest part of plan selection is access to providers in most cases. Depending on medical needs, switching to lower-priced plans could also lead to having no “real” drug coverage until one meets the deductible, which at the bronze level could be $6,000 or more.

It's bad enough that they have “determined” what “essential” health benefits are (maternity, pediatric dental, etc.) and that they have to be baked into all plans, rather than be an option that can be purchased if needed—but now they'll also tell you which plan they are going to put you in if you don't shop again? Terrible idea. Talk about “overreach.”

Renee Palumbo