Preserving True Choice via Diversity of Organization and Universal Standards for Outcomes

Healthcare delivery is inherently local. Every community has its own history; its own needs; and its own resource base. This is especially true in Maryland, with unique communities among its beautiful coasts, soaring mountain ranges, and vibrant urban areas. Indeed, Maryland’s strength comes from this diversity, which is carefully maintained through the deliberate promotion of thoughtful policy, purposeful actions, and local solutions.
In a similar fashion, the Maryland Comprehensive Primary Care Proposal must deliberately promote strategies to strengthen and advance diversity among providers and Care Transformation Organizations (CTOs).
The proposal highlights a desire for competition among Care Transformation Organizations (CTOs); we wholeheartedly agree that competition is the best tool for improvement. However, competition can present tremendous challenges, especially in health care, and many organizations will seek to minimize the level of competition for their own benefit. Competition in health care must be deliberately supported through the selection process and model design so that various options present attractive options on their own, aside from the need to subsidize the CTO-practice relationship. Prior models have shown this to be the case; indeed, the recent trend towards consolidation is evidence enough.
The CTO selection process should not just value having two or more options for practices, but rather seek different types of CTO offerings. By example: choosing between two systems whose integration is based on common ownership is fundamentally different that choosing between a wholly-owned integrated system and a networked system whose integration is based on shared patients and shared data.
An effort to spur and maintain true competition among CTOs would enhance the strength of the state’s Proposal and greatly increase its chances of success.

Reinforcing the Primary Care Physician – Patient Relationship

Every Medicare beneficiary benefits from a strong primary care physician relationship. Primary care physicians “quarterback” their patients’ health care. Those who do so in their own practices maintain the independence that makes their practices unique and trusted.
There are certainly rare cases where the only health need a patient has in a year is a singular acute issue. There are also cases, usually towards the end of life, that a patient’s needs are so intensive they are removed from the community.
However, most health care needs—and most health care spending—are driven by patients with multiple chronic conditions or who suffer from preventable or otherwise avoidable illnesses and injuries. These patients remain in their community, and benefit most from the one-on-one relationship with their primary care physician.
Attribution should revolve around that relationship and the model CTO – practice contract should seek to preserve that relationship. Only in the rarest of cases where it is inescapably obvious that primary care is no long primary to the patient’s health care needs for a given year should specialist or facility attribution be employed.