I also share your view concerning the possibility tiered provider networks present to create a public debate about and improve performance. I would remind you, though, that many of us have watched this one end up in the political and legal la-la land over the past few years - as physicians, hospitals and politicians fight off many attempts by public and private payors to define performance and establish provider tiering as a viable operating model.

I also agree with your conceptual notion about bundled pricing - but like many of my colleagues in this business, have been bitten by the backlash in the provider community against capitation and financial risk - and wonder if we’ll ever get anywhere on that one. My guess would be that some providers will play on terms like this, but many - maybe most - won’t.

Random - there’s a fair amount of pretty solid evidence that Computerizes Physician Order Entry systems both improve quality, reduce errors, and reduce costs - for everyone. In fact, studies in MA have shown that providers get their money back on CPOE investments in two years. I’m less clear about the data on EMR’s, but have heard folks at Partners - and at other provider organizations that have EMR’s - speak glowingly about the positive impact they’ve had on physician knowledge at the point of care, and the quality/safety benefit that comes with that.

But as I’ve noted previously (check out my post on Bill Gates and health care), the physician community is definitely not of one mind on the relative value of this kind of thing, and until they - the users - decide EMRs are a good idea, take up rates will be uneven, to say the least.

Personally, what EHRs gain me in terms of extra information they immediately lose 90% of in terms of extra wasted time and horrible cookie cutter documentation (yes, every patient will now have 20 pages of documentation from every health care encounter, the ultimate goal of American health care).

I agree with you that a government run single payer (Medicare for All) system is just a plain bad idea. While it would save some money on administrative costs, it probably wouldn’t save nearly as much as advocates think. To wit, of the approximately five million people nationwide who work in hospitals, very few of them have anything to do with billing or verifying coverage with insurers. Moreover, while the operator of a single payer system would not have to worry about making a profit, it wouldn’t have to worry about pleasing patients / customers or providers either because there would be nowhere else to go.

I was disappointed to see that neither Partners nor BCBSMA showed much interest in moving the needle on price and quality transparency or tiering of hospitals or doctors (including PCP’s) based on quality and cost, though they did at least mention P4P.

Regarding EMR, to the extent it could be successful in lowering costs by reducing duplicate testing and adverse drug interactions and making it easier to use decision support tools, the benefits of cost reduction would largely accrue to payers, not the doctors and hospitals who would have to implement and maintain the system. It would be helpful if insurers (including Medicare and Medicaid) could come up with an approach that offers doctors and hospitals a meaningful share of any savings from reduced utilization over and above potential bonuses from meeting or exceeding P4P performance criteria.

Finally, a highly regarded and wealthy hospital system like Partners would be an ideal candidate, I think, to provide leadership in bringing about complete bundled pricing for expensive surgeries including not just the hospital stay and the surgery itself but any physical therapy and follow-on care required for an appropriate time after the surgery. Such an approach would require much more cooperation between hospitals and doctors around how to divide up the bundled insurance reimbursement which would, presumably, be paid to the hospital. It would also require risk sharing agreements related to the cost of complications. Bundled pricing would enhance cost transparency, reduce administrative expenses related to billing, and put hospitals and doctors on the same team where they should have been all along.