“A 6-Step Program for Controlling Health Care Costs in Massachusetts” by Nancy Turnbull

Governor Patrick held a meeting of top state officials on Monday to review and accelerate the administration’s focus on efforts to control health care costs. This meeting, which was prompted by the recent Globe Spotlight series on Partners and Blue Cross, is an excellent development. Among other things, the Globe series has served as a wake-up call about the failure of relying on market forces to shape and control the cost of the state’s health care system. Partners and Blue Cross are not the only culpable parties in the feeding frenzy that the market has produced in the last two decades. State inquiry and action must also address other providers that have developed and exploited dominant market positions, insurers that have had neither the resolve nor the power in many areas to address the causes of rising costs, employers, who have done little and often hindered approaches that might have made a difference, and government, which was missing in action for nearly 20 years after the state began its romance with the market in health care.

Our collective behavior in dealing with rising health care costs in Massachusetts shows many of the classic symptoms of addiction: denial (“health care costs aren’t really a problem…”costs aren’t really higher in Massachusetts”); rationalization (“our quality is higher so our higher costs are justified”…. “health care is the only growth industry in the state”); blaming others (“providers who aren’t doing well are just whining”….”we insurers can’t really do anything about rising spending”….”mandated benefits are the real problem”….”consumers are too fat, smoke, don’t get enough exercise, and don’t have enough ‘skin in the game”); the need to use more to get the same effect (“the suburbs deserve high quality care too”….”the health care industry in Massachusetts is a treasure that must be preserved at any cost”); and, an inability to meet other responsibilities because of our addiction (just look at how rising health care spending is crowding other important forms of public and private investments).

Members of my family and many others have benefited from the 12-step approach to different types of addiction. Maybe it’s time for a similar approach to our health care cost problem. Here are my ideas for an economical, 6-step program for health care cost control:

#1: Admit that health care costs have become unmanageable: Costs have been a “crisis” for as long as I have worked in health care. We have brief periods of sobriety when costs moderate, but then we relapse. This behavior is typical in families with addiction problems. We need a “health care cost intervention,” perhaps with Governor Patrick as the facilitator. We need to confront the problem and talk openly about how it affects us, and the role that each of us plays in contributing to the problem, be it as deniers (providers), enablers (insurers and employers), rescuers (consumers), or martyrs (government).

#2: Embrace a greater power to help restore us to sanity and strength: The market and deregulation have failed in health care. More of the same will not solve our problems. We need active engagement by and a much stronger role for government.

#3: Examine past errors with the help of experienced people: I would like to see Governor Patrick convene an independent body to help develop a health care cost control action plan over the next 90-120 days, one that will make a real difference in moderating costs over the next few years. Part of this plan should be to go back to the drawing board on the Health Care Quality and Cost Council, which has been well intended but ineffective. A better approach might be to give responsibility for action on health care cost control to a state agency, with assistance and oversight by a small independent board that has a carefully focused charge and a composition that makes sense.

#4: Admit the nature of our wrongs and make amends to those we have harmed: This includes admitting that health care is a scarce resource and that rising health care spending, particularly public spending, has an opportunity cost—we must forego other ways of spending the money when we spend more on health care. We need to talk about the harm that unbridled spending does to the strength and vitality of other important services, particularly at a time of financial crisis for the state. This harm includes lower investments in public health, education, income supports, job training, roads and bridges, environmental programs—ironically all areas where more spending would likely improve population health more than additional spending on medical care.

#5: Learn to live a new life with new behaviors: My list of recommendations includes:

• Develop a comprehensive statewide uniform provider payment system: Our current provider payment system is a major reason for rising costs. Many parties are working on provider payment reform, but in a piecemeal, uncoordinated and slow manner, and with no ability to deal effectively with dominant providers and no attempt to include Medicare, the most important payer. The state’s new commission on payment reform, which will finally meet for the first time next week, must move swiftly and boldly to recommend fundamental payment reforms, including approaches such as having the state set uniform rates of payment for the same risk-adjusted service and pursuing a federal waiver to allow Medicare to participate in any new system.

• Reinvigorate centralized planning to restrict and rationalize capital investments: The Globe series makes clear that we need some supply side controls on the proliferation of capacity and technology in our health care system. These controls must consider existing as well as new capacity, and both inpatient and ambulatory facilities. Massachusetts might consider a process similar to New York’s independent commission on health care facilities, which made recommendations about which facilities were not needed and should be closed.

• Force collaboration and standardization among payers: Our competitive health insurance system results in enormous administrative complexity and costs. There is little value in the proliferation of different insurance products, disease and utilization management programs, payment methods, and quality improvement initiatives. For example, imagine how much progress we might make in the management of chronic diseases if we had uniform approaches, including payment, across the system. Efforts to simplify the administration of the system are moving too slowly. Let’s lock the health plans in a room with supervision by the Attorney General until they come up with a comprehensive and speedy plan to take administrative complexity and costs out of the system. And while they’re at it, let’s understand and address the reasons why health insurance costs so much more for smaller employers and individuals and what role insurers, and others, need to play in addressing this problem.

#6: Have a spiritual awakening and lead the way for others: If Massachusetts had unique advantages when it came to expanding coverage (e.g., a lower uninsurance rate), we have unique disadvantages in seeking to control costs (e.g., higher costs, more teaching hospitals, more jobs in health care). This means that success in moderating health care costs here would be a more extraordinary and inspiring achievement to others than our success in expanding coverage.

As with any form of recovery, confronting our addiction to more and more health care spending will require willpower and, what my uncle, sober for 20 years, calls “want power.” I believe we could develop an achievable state action plan to moderate health care costs. Only time will tell if we have the collective “want power” to do what must be done.

Nancy Turnbull
Harvard School of Public Health

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  • http://www.kaiserhealthcoverage.com Kaiser quotes

    Ms Mitchell, the facts on Ms. Turnbull’s actions and financial compensation for such actions speak for themselves. Are you challenging the facts? And pray tell, do let us in on your thinking about this remark: “find a more appropriate target.” Who do you have in mind?

    Please know that one person’s “ad hominem attack” (a phrase that’s oh-so-popular with the bourgeois) is another person’s civil right to speak the truth and expect some accountability.

  • Michael Metzler

    As a retired hospital CEO, I am in full agreement with Nancy and can admit my own short-term focus on my own institution, trying do the best for it within the rules of the game.

    Now retired, i am quietly developing my own views on how to drastically change the healthcare system. I hope that soon I can become an active participant in change, at least as a writer. Besides healthcare, I was an executive in a retail company, an academic and now I a neutral as a labor arbitrator. I can attest first hand to the myriad of individual self-interests.

    If we could just think backwards from what is best for the patient and the public rather than make modifications on the base of what we have now. I will give myself and others the benefit of the doubt that we have felt our mission has been to protect our interests and if we did that, it would work in the best interest of the patient. I am afraid that this micro approach does not add up to the patient’s best interest.

    The healthcare system is too complex with too many contradictory interests for that to be the outcome. It is amazing how concepts that seem to have value on the surface work against the patient’s best interest. We talk about consumer-driven healthcare and that people should have skin in the game as they access healthcare services. So we charge them for a portion of their prescriptions, this makes them unaffordable, and they suffer the consequences of not purchasing them at all. We say that , as with the private sector, there should be competition among providers in a free market. Then we listen to a Blue Cross executive state that sure, we pay more to Partners because they have more “clout.” What does this mean for a patient in a commumity where the hospital is not a member of Partners, gets substantially lower rates, and cannot provide the latest technologies, appropriate staffing levels, and an electronic medical record? I cannot blame Partners for developing “clout” to get what it needs for its patients. However, should “clout” be accepted as the right market model and inevitably produce a variation in the quality of care provided to patients in different communities in Massachusetts?

    For three decades I have watched changes take place in all aspects the healthcare system. Concepts such as state regulation of rates, capitation, managed care, the formation of healthcare systems to balance power in the market place, deregulation, the use of quality measure to determine payment rates, physicians becoming competitors in ancillary services, for-profit hospitals, etc., etc. I have gone back and forth on whether we practically can expect to make a major overhaul such as having a single payer with private providers. Gradualism always seems to win the day because there are so many separate interests to be satisfied, many of which cannot be necessarily defended as being in the best interest of the patient.Historically, major changes in an aspect of life in America have not come until we have a crisis. I now believe that the crisis of this moment must drive us to major change in our healthcare system.

    I am worried whether the State’s efforts will be successful. As I look at the participants, I wonder if they will be able to step back from their own separate interests and be willing to make major change on behalf of patients and the public.

  • Nancy Turnbull

    My friend Charlie said my 4th step, “Admit the nature of our wrongs and make amends to those we have harmed” wasn’t nearly the type of “searching and fearless moral inventory of ourselves” that 12-step programs demand. Here is his version:

    “Annually, the US health care system leaves more than 40 million of us without access to health care; another 15 to 20 million with inadequate access to health care. This translates into untold anguish, fear, pain, unnecessary disability,
    and early death. Men, women and children. All day, every day. Anyone raised in a low income or working class family would have more or less known this from childhood; would have remembered the hushed parental discussions about whether to keep a doctor’s appointment or buy shoes for the kids; to have that leg looked at or to hope its nothing and buy the groceries.

    I have early onset heart disease and have had a heart attack in my life. I went through a period without health insurance afterwards. During that period, I awoke in the middle of the night on several occasions with chest pain. Knowing I would
    be admitted through the ER if I went to the hospital, knowing the costs associated with
    that stay and the resulting workup…I took two aspirins, turned back over and went to sleep hoping for the best. A few months later, with health insurance in hand, I had the same symptoms and had them checked. A major artery was significantly blocked; I needed and received my third stent implant. One more bullet dodged.

    Middle class health professionals, after many years of study, just seem to be discovering this truth: that if people don’t have health insurance, if they can’t pay for health care, then they don’t seek it and they don’t get it. They defer
    making appointments, arranging for hospitalizations, pharmacy refills, follow-up visits to the doctor–whatever–and they use what funds they have for the other more pressing
    costs of daily living. And this produces the anguish, fear, pain, unnecessary disability, and early death. Like any other condition leading to fatalities, the US healthcare system ought to have a death rate calculated for it and reported on an annual basis by the US Center for Disease Control (CDC).

    Those of us who spend careers in health care making “good money” off the system; those who have never once thought about why and how it needs to change; who have spent professional lives more or less knowingly moving the chairs around on the
    deck of a Titanic; those who have never taken a step in any direction to help bring about
    any change, are completely, utterly and irrevocably complicit in all of this human pain and suffering. We are the only western, industrialized country remaining that treats its own people like this and we do it because we are the only western, industrialized country where it is still socially acceptable–and even
    praiseworthy–to make the very last buck possible off of human pain, suffering and death. This is where the fearless moral inventory of ourselves
    should come in, for we are the ones who know enough of the system to dissent from this, to
    scream of its injustice, to challenge its social acceptability, and for the most part, in very large numbers…we do not. “

  • Brandon Shriver

    Ms Mitchell, the facts on Ms. Turnbull’s actions and financial compensation for such actions speak for themselves. Are you challenging the facts? And pray tell, do let us in on your thinking about this remark: “find a more appropriate target.” Who do you have in mind?

    Please know that one person’s “ad hominem attack” (a phrase that’s oh-so-popular with the bourgeois) is another person’s civil right to speak the truth and expect some accountability.

  • Dolores Mitchell

    I rise to the defense of Nancy Turnbull from the ad hominem attacks from Brandon Shriver, although, given the enornouse respect in which she is held by so many, it probably isn’t necessary. Nancy Turnbull is one of the most principled, thoughtful, and decent people I know in the health policy field. Neither personal nor professional gain has ever been her motivation. Argue, if you wish, with her point of view, but keep the totally unjustified personal attacks out of it–or find a more appropriate target.

  • http://www.californiahealthplans.com Jack

    I agree Clyde. Even if I’ve been with health insurance companies for years already, I can’t help thinking about a future where the fruit of our sweat will barely be enough for paying premiums.

  • Clyde

    Ms. Turnbull makes some excellent suggestions for tinkering with the current system, which I agree should be implemented rapidly. Why do health insurance premiums have to rise by 10% every year? Any other cost that rises at that rate eventually crashes, which leads me to think that we have some sort of a monopoly at work here.
    I have to agree with Mr. Shriver, however, that Mass-Care’s single payer system is the way to go.

  • http://www.thehamperandgiftpeople.co.uk Mike

    Costs for healthcare are spiraling out of control in many states. Nancy Turbull has some excellent steps to bringing it more in line in Mass. I like her ideas. Well thought out and worth a shot.

  • Brandon Shriver

    Perhaps there is a place for some of the suggestions Ms Turnbull glibly outlines above in her woeful addiction metaphor, but only if these are details within a larger, truly reformed system of healthcare financing and delivery that places people’s needs before corporate profits. Enough tinkering already, voters and others are increasingly demanding real reform.

    Interstingly, in this entry Ms. Turnbull apparently wants to have it both ways as she continues in her lucrative role as a “Player” in the state’s corrupt health policy arena. In this blog and many other writings, Ms Turnball seeks to present herself as a champion of the people (with her repeated use of “we”) while she conveniently omits any reference to the fact that she herself has been for many years–and continues to be–feeding at trough of greed-driven corporate healthcare in Massachusetts. Ms TUrnbull’s central role in the creation and implementation of a state law that mandates purchase of private health insurance and, additionally, siphons almost a billion dollars in new public spending to subsidize purchase of those private insurance products is something she herself seems to be in denial about. Does this raise a concen of questionable ethics at play? Is wbur culpable, too?

    As a fellow researcher recently pointed out to me, one simply needs to do a Google search on Ms Turnbull and you’ll see evidence of her years on the payroll of Blue Cross and Blue Shield of Massachusetts (see partial results at this link http://www.google.com/search?q=%22Nancy+Turnbull%22+blue+cross+blue+shield+medicaid+policy&ie=utf-8&oe=utf-8&aq=t&rls=org.mozilla:en-US:official&client=firefox-a ) Ms Turnbull’s corporate health care connections have brought in lots of Blue Cross and Blue Shield money to her current employer, the Harvard School of Public Health. Back to the central issue.

    There actually is a “we” grassroots-driven health reform movement underway in Massachusetts. I have just learned that this group Mass-Care is comprised of over 100 organizations representing a half-million MA residents. Sadly, it seems that Mass-Care’s work gets scant media coverage. This is likely due to them not buying ad space in said media outlets.

    A recent Mass-Care project was written about on this wbur blog in November. You can read about it here http://commonhealth.wbur.org/wbur-posts-and-stories/2008/11/single-payer-question-on-the-ballot-in-10-districts/

    On their website I read that Mass-Care’s coalition has crafted a universal health care bill that uses streamlined financing called “single payer” seeking to create affordable universal coverage. They are busy educating the public and elected officials about it. The bill is to be introduced in the state legislature this session. Learn more about the bill and if you think it makes sense then contact your legislators to sign on. Details can be found at http://www.MassCare.org.