New York Times reporter Kevin Sack dug deeper, unearthing the roots of the dilemma: serious cost containment would cut the income of the formidable Massachusetts medical establishment. As Brandeis health policy professor Stuart Altman told the Times: “Really controlling costs requires just stopping spending.” In other words, what’s needed is a limit or cap on spending allocated to medical services. Nobody is talking about that, either in Massachusetts or nationally.
“[Cost control] was really never an active part of the conversation,” says Nancy Turnbull, a professor at the Harvard School of Public Health. The law’s biggest nod to cost containment was the Health Care Quality and Cost Council, which has created a Web site to help consumers shop for the best care at the lowest price. The MyHealthCareOptions site gives some data about quality measures for hospitals and costs for some procedures. According to the state, 2,700 people visited the site during the last three weeks in May. It’s hard to say whether they found it helpful. It’s much easier to say the site does not reduce costs, if at all. There’s little evidence that consumer shopping reduces the price of medical services.
The state built its plan with federal dollars, assessments on employers, redistributing existing funds, and new general revenues. “It needs a dedicated revenue source,” says Boston Medical Center vice president Tom Traylor. “It was all just cost shifting.” So the state has had to raise copayments and premiums for people receiving subsidized coverage, and has increased tobacco taxes to help make ends meet. This year, the state is facing a $4 billion budget gap; the state senate has proposed taking away subsidized care for some 28,000 legal immigrants who are now eligible.
Another cost-control strategy is to enact recommendations made by the Special Commission on the Health Care Payment System, one of which is to give providers a negotiated set payment that covers all the care a patient would need for the year. “The fee-for-service system has all the wrong incentives,” a commission member told the Globe. That sounds an awful lot like what policy experts said fifteen years ago. So do these new “global payments,” which sound like the capitation payments HMOs made to providers in an effort to cut costs. As the great HMO backlash from patients and docs flared up, capitation payments gradually disappeared for some providers and were replaced with, yes, the old-fashioned fee-for-service arrangements.
I asked Sarah Iselin, the state’s commissioner of the division of health care finance and policy, about the difference. She said this time payments would be coupled with performance measures of quality, adding “it’s different from the capitation of the 90s.” I asked a health plan official the same question. He said “they really mean the same thing, for better or worse. Capitation has become a dirty word. What the commission has tried to do is rebranding.”
A lot of newbies cover health these days, and might not be versed in all the payment jargon. The trick will be for reporters to decipher the new buzz words and really deconstruct their cost-cutting potential. Here’s another shout out to the Globe for doing just that. Its story in early May told readers: “The new payment system the commission expects to recommend has been tried before.”
Connecting various and sundry dots and ending with a Rodney Dangerfield lament:
In the past two weeks, Atul Gawande, a surgical oncology attending at Brigham and Women's - one of the Partners anchor institutions, published a more is not better health costs article in The NewYorker, looking at usage and costs in McAllen and El Paso, Tx. He should have saved travel costs and simply strolled around the Longwood Medical Area in Boston and then driven an hour or so north up to Dartmouth. He might as well as just looked in the mirror and acknowledging that he has the same business first blinders on as his esteemed colleagues in McAllen.
The Boston Globe also reported that a low cost mobile primary health van travels to low income neighborhoods with disproportionately high percentages of residents who are uninsured or who have accessibility problems, and that this service has saved over 2 million dollars in preventing avoidable hospital admissions over a one year period.
The Harvard brand has an outsized influence in national health policy. Yet it's just as guilty of pushing up costs and protecting its own corporate interests at the direct expense of patients.
What Harvard, Dartmouth, Princeton, Cornell and Brown don't have are professional nursing programs which provide baccalaureate through doctoral education,field robust nursing research agendas and include professional nursing issues in driving university curriculum, research and health policy.
They need to get educated, and they need to engage nurses and professional nursing in critical health policy arguments and formulation. Morbidity and mortality rates are significantly decreased when patients are cared for by nurses with a minimum of a baccalaureate nursing education (IOM, Aiken). And overall nursing costs are so minimal that they don't merit a carve out or mention in overall US healthcare cost breakouts.
In what other national policy discussion would a service with a very high ROI be totally ignored?
#1 Posted by annie, CJR on Wed 10 Jun 2009 at 02:12 PM
The cost of a product and how it is paid for are two separate issues. Insurance is how we pay for health care and it works by applying the concept of risk pooling. What is lacking most in our current system is a fair and equitable way for people to access insurance.
MA has taken very big and bold steps in trying to address this issue, but there appears to be two major missing elements. First, there must be some form of community rating where insurance rate are established based on basic demographic information like age and sex and not health condition. Not only must pre-existing conditions be covered, but rating with any information on health status should be illegal.
Second, there can be no exemptions from participation. None. A $1,000 tax penalty doesn't cut it when the average health insurance premium far exceeds this amount.
Establishing a fair and equitable system that universally provides for access to health insurance to pay for health care should be priority number one. There are plenty of quick fixes available to do this right now.
Addressing the cost of care issues is priority number two and unfortunately there are no quick fixes available. If we do not fix the payment problem, it really doesn't matter what it costs.
#2 Posted by Frank Erwin, CJR on Fri 12 Jun 2009 at 10:24 AM