Baskets for Back Pain

In discussion with some colleagues in response to this recent post, I became aware of some "innovative" solutions that our fellow Minnesotans are apparently working on when it comes to improving health care for the most expensive conditions. According to the website, they are setting up "baskets of care" for the following conditions:

1) Asthma (children) - Management of asthma as a chronic disease

2) Diabetes - Without co-morbidities, does include hypertension and hyperlipidemia

3) Low Back Pain - Management of acute episode of low back pain

4) Obstetric Care - Consider prenatal, uncomplicated vaginal delivery, cesarean section delivery

5) Preventive Care (adults)

6) Preventive Care (children) - Well child care, preventive care, normal newborn care

7) Total Knee Replacement - Inclusive management from preoperative phase through rehabilitation phase

Little detail is provided on how they derived the list, but I suspect it's based on some combination of high volume/high expense (ie, low back pain) and opportunities to prevent some of it (ie, the focus on preventive care). The baskets apparently include "collections of health care services designed to treat particular health conditions or episodes of care" with a case rate form of reimbursement in which the provider is paid a flat fee, thus assuming some element of risk for the outcome. The approach of course is being pitched as a "major reform in the way we pay for health care" in Minnesota.

The concept of case rated reimbursement actually has some merit, but this is only the case assuming a level playing field in which all health providers share in the potential risk and reward. I am purely speculating in this instance, but if history of previous health care reform efforts is a guide, I am willing to bet that these baskets don't include the very interventions that got us into this mess in the first place (health care meltdown a la economic meltdown coming to a country near you...), primarily drugs, imaging, and procedures (ie, injections and surgery primarily). In other words, the playing field is anything but level, so any examination of the extent to which reform might work has to be subjected to the sniff test.

What do you suspect the likelihood is that physicians have been able to carve out their own special basket for things like drugs, imaging, and procedures such that they continue to be paid on a fee for service basis while we "plankton providers" (yet the only ones offering meaningful hope for reform) get case rated? I am willing to bet big. If true, highly effective care gets subjected to case rates (which again can be a very reasonable solution so long as everyone plays by the same rules), while largely ineffective procedures will continue to get handsomely and disproportionately rewarded, which only continues to make the problem worse.

Perhaps someone more familiar with the process in Minnesota can confirm or disconfirm whether a rat really exists in this or if perhaps there is actually real reform under way. I highly doubt real reform because you don't see the Golden Rule of health care policy in the U.S. get violated very often...policy making has nothing to do with what's best for the patient or our country as a whole but rather exists to serve special interests. So, while the Declaration of Independence might stipulate that all men are created equal, some in health care have bigger baskets than others and that's just the way it is. What say you?

John