As a member of the Advisory Council to the Health Policy Commission in Massachusetts, I was very interested in following the internet broadcast of the annual HPC Cost Trends Hearings early in October. At the core of the presentations was a debate about healthcare costs.
For me the high point came when Attorney General Maura Healey and her staff made the sort of leadership statements that suggested to me that she was not in harmony with what Governor Baker had said earlier in the hearings. The Governor had offered an interesting combination of truths and faux statistics that added up to an attempt to rationalize going slowly into the future of healthcare reform.
The Governor’s remarks began with questioning whether there really a healthcare cost problem. He presented a “fact” to support his doubt: If you divide what Massachusetts spends on healthcare by its per capita income you get a factor for Massachusetts that is lower than all but three other states.
My heart sank. Would he really swallow this bogus statistic as a reason to question or create doubt about the efforts to make the hard choices to transform the finance and delivery of care in the state? Could he be blind to, or worse yet, not really care about the impact of the cost of care on individuals, on taxpayers, and on employers? Would this be his justification for “going slow” and mollifying the fixed interests of the status quo?
The Governor associated his comment with a litany of economic benefits that our expensive but world-renowned academic medical centers bring to the state. They employ thousands, more than any other local industry. They attract the business of big pharma and high tech companies and other industries that gather here to be close to what is happening on the leading edge of science. These industries come to Massachusetts because they want the opportunities that our institutions offer them to test the applications of the medical science that they produce. He seemed to be asking, “Do we want to mess with this picture?”
After casting doubt on the idea that healthcare costs need to be addressed, the Governor did a reasonable review of our financial challenges, the chaos in the delivery system, and the operational challenges of moving healthcare finance and care delivery from the status quo to new approaches that might be risky but also might be the way that we should go. I could not help but think that his introduction of uncertainty and caution changed the tone of this year’s hearings from the urgency that has characterized the HPC Hearings in the Patrick era to a considered “let’s think twice about what we are doing.”
The victims are the disadvantaged whose need is obfuscated by the excess benefits and wealth of others. She talked like a physician who understood population health. For me her soft tones and unemotional restating of reality were a breath of fresh air after listening to a day of diverting conversation that was directed, it seemed to me, by a strategy designed to stall the conversation while whitewashing a less than acceptable status quo.
She made the point that affordability affects access in a way that undermines our efforts to improve health. You know that and I know that. Everyone in the room knew that, but she presented the principle as if we don’t know it because to know it and to do nothing to make care affordable is worse than not knowing it. To know it and ignore it suggests that our focus is more likely to be self interest than a passion to provide the best care for everyone.
Using these ideas she attacked unwarranted price variation and carried the analysis further than anyone did before or after her. Her conclusion was that we can’t achieve the objective of a competitive marketplace where innovation and attention to quality are rewarded, if some institutions get less than a fair share of the reimbursement pie.
The Attorney General did not hold the floor for long. She delivered a strong statement without drama which left no room for the consideration of avoiding the hard decisions which had been the pattern of the previous day. After speaking for less than fifteen minutes she turned the presentation over to her able staff. Follow the link below to see the presentation that her staff gave.
On the last three slides you will find the recommendations of the AG’s team which I have copied below:
- Simplify and expand demand-side efforts: Require clear, easily compared information on the cost and quality of different insurance plans and provider systems for employers and consumers at the time of health insurance plan and PCP selection. Simplify and strengthen how tiered networks are designed. Promote consumer access to and understanding of health care cost and billing information.
- Consider Ways to implement supply-side incentives and penalties more evenly: monitor variation in health-status adjusted global budgets. Evaluate provider performance under statewide cost growth benchmarks in ways that take into account existing differences in provider efficiency.
- Monitor and address disparities in the distribution of health care resources: Consider forms of directly regulating the level of variation in provider prices and/or medical spending. Monitor income and health status adjusted medical spending by zip code on an annual basis. [Much more beneficial as a metric than the gross one-lump state evaluation of income v. healthexpense suggested by the Governor] Promote the development of population health status metrics that better account for socioeconomic risk factors.
Societal change is a slow process but the existence of the hearings is itself evidence that the change will come. Blue Cross used the hearings to announce that their alternative quality contract methodology will be extended to PPO products starting January, 2016. I can hardly wait for 2016. It will be interesting to see how much progress is made over the year toward the Triple Aim Plus One or as Dr. Ebert said 50 years ago, how much progress we will make next year toward what he called a “conceptual framework and operating system that will provide optimally for the health needs of the population.”
Ebert was right then, and it is still true now that: “The existing deficiencies in health care cannot be corrected simply by supplying more personnel, more facilities and more money.” I believe that if we can develop a collective will and find leaders and followers who have a passion to live in a better world, we will make progress.
