Recommendations:

1. Modify the volume formula to reflect increased population utilization and fund hospitals accordingly using the “money should follow the patient” strategy. Community hospitals cannot be expected to provide care to more Maryland residents without additional resources. Free standing medical facilities and other lower acuity providers cannot provide the same services of full-service inpatient hospitals at a time of increasing population growth.

2. Evaluate the current funding methodology which has resulted in perverse incentives which ration patient care.

3. Incentivize hospitals financially to improve their offering of innovative procedures and surgeries which improve health outcomes, including requiring hospitals to pay call coverage to independent specialists.

4. Develop an independent complaint reporting system which will encourage patients and clinicians to share their feedback and concerns about inpatient care, and create a multi-disciplinary, non-biased committee to assess trends and address these complaints with specific hospitals and/or initiate improvements in hospital funding for those facilities which address complaints effectively.

5. Evaluate the disproportionate funding to hospitals within Maryland and reallocate funding to community hospitals where there is increasing demand and the need for community-based primary care which will help to achieve the goals of AHEAD. While it is understandable that funding is needed in our tertiary care facilities and trauma centers, population health strategies and improved outcomes will result from greater funding to community hospitals and community-based physicians and other outpatient services.

6. Improve the transparency of HSCRC funding strategies. It is complex and not easily understood. The general public is unaware of hospital funding methodology in Maryland or the impact it may have on their medical care.

7. Develop a publicly available and consistently applied transparent rating system for hospital quality and efficiency accessible to patients, physicians and other providers to inform consumers of quality health care.

8. Incentivize quality primary care rather than the number of visits. Physicians who care for patients with complicated health conditions should be compensated properly for the time and resources required to treat a patient effectively.

9. Medicare has established a rating system for hospitals, nursing homes, physicians and many other facilities called Medicare Compare. According to the medicare.gov website, “Medicare Compare uses a methodology that primarily relies on standardized quality measures, including process measures (what a provider does), outcome measures (results of care), patient experience measures, and sometimes structural measures (characteristics of the provider or facility), all gathered from patient medical records, claims data, and standardized surveys to generate a comparative rating for healthcare providers, allowing patients to compare quality across different facilities and doctors on the Medicare website; this often takes the form of a star rating system, where higher stars indicate better quality.” Maryland’s rating system could be based on similar measures but also on emergency room efficiency, acquisition of innovative equipment, staffing, etc. This rating system needs to be publicized. Hospitals should strive to achieve the highest level of quality and efficiency.

10. Consider “medical loss ratio” type reporting for hospitals. Medical loss ratios are a significant aspect of the Affordable Care Act.[3] They have been implemented in Maryland to hold health insurance companies accountable for the amount spent on medical care of every premium dollar and expose the amount spent on non-medical care expenses. The “medical loss ratio” concept applied to hospitals could limit the amount spent on administrative salaries, marketing, and non-medical projects including the building of non-patient care facilities. Hospital global budgets should be adjusted by the amount of administrative costs vs. actual costs of medical care. Hospitals should be incentivized to partner with community primary care physicians and urgent care centers to improve access to care, cost control and population health. By reporting both the resources spent on administration and health care to the HSCRC, hospitals will be held accountable for the medical care they are providing and be incentivized to meet certain targets of care. National and regional comparisons of administrative costs should be considered.

11. The payment structure for primary care physicians should move away from RVUs and toward high-quality care to compensate for time and resources needed to effectively use clinical guidelines and patient education to improve patient care and outcomes.

12. Expand facility fee payment policy to include additional medical care settings. By leveling the playing field, more cost-effective, highquality care can be performed in the outpatient setting, including independent surgery centers and medical practices increasing patient access. HSCRC should institute policies to ensure the fees are supporting patient care.

13. Enhance access to and payment for remote patient monitoring for patients enrolled in MDPCP or Medicaid Primary Care Program. Remote patient monitoring has demonstrated success in management of the care for patients with long-term chronic conditions.

14. Create an environment which encourages, facilitates and rewards cooperation, not competition, among providers of care in the outpatient setting. Finding successful ways for hospitals and all physicians to align and work together to improve patient outcomes is critical. Acquisition of medical practices by hospitals often increases costs. Investing in independent primary care to improve outcomes through programs like MDPCP and the new Medicaid Primary Care Program are helpful to manage care at the local level, yet many physicians find that the administrative burdens of such programs limit their optimal success.

15. Create legislation that no payor operating in Maryland can pay less than Medicare to primary care and behavioral health physicians working exclusively in Maryland.

16. Expand Medicaid coverage and payments to be equivalent to Medicare for the Top 25 CPT codes in the outpatient setting. If the proposed budget for Maryland is approved, Medicaid E&M codes would once again be equivalent to Medicare. Unfortunately, patients have little or no access to medical or surgical care for chronic conditions.

17. Eliminate prior authorizations for all practices participating in MDPCP and the new Medicaid Primary care program. This would immediately increase interest in participation if administrative burdens could be reduced.

18. Eliminate duplicative credentialing requirements for participation in Medicare and Medicaid managed care plans (like Medicare Advantage) if clinicians are already credentialed by traditional Medicare and Medicaid. This will improve access and expedite care.

19. Encourage hospitals to collaborate with and support financially nonprofit clinics and organizations which provide medical care in the community to enhance outreach to underserved populations (e.g. Mobile Medical Care, Mercy Clinic, etc.)

20. Population-based payment methodology must include payments for care provided by community-based primary care physicians to ensure appropriate care for chronically ill patients to reduce hospital admissions. 

 

[3] Hall, Mark A. and McCue, Michael J. How the ACA’s Medical Loss Ratio Rule Protects Consumers and Insurers Against Ongoing Uncertainty. Commonwealth Fund Issue Briefs. July 2, 2019.