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February 21, 2019

Maryland Total Cost of Care Model: Transforming Health and Health Care

Author Affiliations
  • 1Center for Medicare and Medicaid Innovation, Centers for Medicare & Medicaid Services, Baltimore, Maryland
  • 2Health Services Cost Review Commission, Baltimore, Maryland
  • 3Maryland Department of Health, Baltimore
JAMA. 2019;321(10):939-940. doi:10.1001/jama.2019.0895

States have a unique combination of regulatory levers, including relationships with health care systems and payers, and have knowledge of the health care needs of their residents; thus, they are well-positioned to lead the effort to align incentives across the health care delivery system to improve quality and value. States can spearhead care redesign efforts and collaborate and negotiate with Medicaid and private health care payers, but statewide health care transformation may be limited without participation from the nation’s largest public insurer: Medicare. Models tested by the Centers for Medicare & Medicaid Services (CMS) Innovation Center are one opportunity for Medicare participation in such efforts, and the Innovation Center has the authority to waive certain Medicare payment rules for the purposes of testing models, which can provide flexibility to states committed to transforming health and health care for their residents.

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    2 Comments for this article
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    How To Further Decrease Health Costs
    Edward Volpintesta, BA, MD | Bethel Medical Group, Connecticut
    The authors mentioned that with CMS’s waiving some of its regulations, Maryland is transforming health care. Hospital costs are decreasing and plans are underway to extend into the out-patient sector by addressing behavioral health, substance abuse, and health-related social needs all of which contribute to rising costs.
    Though it was not mentioned, the ordering of unneeded CT scans and MRIs, blood tests, and consultations to ward off frivolous malpractice suits also contributes greatly to rising costs.

    Maryland’s health care experiment will be even more successful if Medicare would protect physicians against frivolous suits. Health courts are a possibility.
    They would compensate patients quicker than civil suits, cut down on court and attorneys’ fees –and lower physicians’ instincts to order unnecessary tests and consultations.
    CONFLICT OF INTEREST: None Reported
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    Population Health
    Paul Nelson, M.D., M.S. | Family Health Care, P.C. retired
    I am surprised that one attribute of Maryland's health was not identified for improvement. Within a state-by-state listing of maternal mortality for 1987-1996 (1999 MMWR) and for 2005-2014 (Ob & Gyn 2016), Maryland ranked 41st in the first listing and 43rd in the second. We should remember that nearly 700 women die in the USA annually just because they lived in the wrong OECD nation before conception. The median maternal mortality ratio increased by 239% between the two data sets. Incidentally, this is nearly the same as the increase in our nation's mass shootings between the two same intervals.

    As a corollary, it is estimated that only 5% of health spending occurs for 50% of our nation's citizens. It is likely that over-all health spending as well as maternal mortality incidence will be unchanged in eight years without a mandated increase in the level of health spending for primary healthcare.
    CONFLICT OF INTEREST: None Reported
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