There is a three-fold variation in per capita spending on Medicare patients across 300-plus health care markets in the United States, according to the Dartmouth Atlas of Health Care. Lurking in that variation lie important clues to reducing the overuse of unnecessary services, a key to limiting the growth of health care spending. Surgeon-journalist Atul Gawande traveled to McAllen, Texas to investigate those clues and wrote about it in the June 1 New Yorker magazine.

McAllen had the second highest spending per Medicare beneficiary in the country in 2006 – $14,946, behind only Miami. Gawande uses data to dismiss explanations for the excessive spending offered by area physicians – an unhealthy population, better services, the threat of malpractice suits – and points out that in El Paso, a city with similar demographics and public health statistics, spending is half of what it is in McAllen. He argues (and several of the doctors he speaks with agree) that McAllen’s cost disparity is largely the result of a culture of medical practice that overuses intensive, expensive technologies and services.

Dartmouth researchers and others have compellingly argued that, in medicine, more is not necessarily better. Read more…

Health care reform for the nation is coming. And certainly there are unanswered questions. When will it happen? Who will lead the efforts? Will it be good enough to address health care’s real problems of cost, quality, access, and equity?

This presents physicians with a challenge – and opportunity. Physicians are the one key link between patients and a system that currently is in chaos. I believe that physicians can work to ensure a workable health care delivery system for our future.

Physicians have two key imperatives in my view. The first and most obvious is clinical. This is our prime directive, and we must never deviate from the pursuit of the safest and highest quality clinical care.

The second is less obvious, but now especially, no less important. It is, to participate in the efforts — without ever sacrificing our primary clinical role or the pursuit of excellence in quality — to ensure that we have a health care system that is affordable, sustainable and accessible by all.

We’ve seen in Massachusetts that providing universal coverage, while an admirable goal, does not ensure patient access or an adequate work force. Read more…

check out this interview with Dr. Atul Gawande. It covers some of the same issues he describes in this New Yorker article, and includes several recommendations that are in sync with changes the state’s commission on health care payments is proposing.

Martha Bebinger

The stakeholders who worked together for so long to pass a health care reform law in Massachusetts have much to be proud of. They set out to achieve near-universal coverage and, in just three years, that’s what they’ve accomplished.

At 97 percent, Massachusetts enjoys the lowest rate of uninsurance in the nation. The third annual Massachusetts Health Reform Survey conducted by The Urban Institute — the results of which are being released today — also shows that Massachusetts residents enjoy unparalleled access to health care. Ninety-one percent of state residents, regardless of income and regardless of whether they have public or private insurance, now say that they have a regular source of care. Before health care reform was enacted in Massachusetts, only 86 percent of state residents said the same. Meanwhile, the latest public data from the National Health Interview Study (2007) shows that only 82.7 percent of residents around the county say they have a usual source of care.

The survey of approximately 4,000 Massachusetts working-age adults also found that Massachusetts residents were more likely to have had doctor and dental visits in the previous 12 months than they were before the health care reform law was enacted. But the survey also shows that we have more work left to do. Read more…

Been there, done that…sort of. Massachusetts passed a health coverage law in 2006. Now some state leaders say it’s time to move agressively to control health care spending. A special state commission is mapping a plan to redirect billions of health care dollars. The idea is to spend less by rewarding doctors for helping patients stay healthy instead of rewarding them for delivering unlimted care when patients get sick. If that sounds straight forward its not. We frame the politics of trying to sell this major change to the business community, the public and politicians on Beacon Hill.

First, lets establish, this is big undertaking that would touch the lives of virtually everyone in Massachusetts. The Special Commission on the Health Care Payment System is proposing to reorganize the way more than $55 billion is spent on health care in this state every year. With that much money at stake, those involved and those watching were surprised that a diverse group of commission members agreed early and easily to throw out the way things work now, where doctors and hospitals are paid based on how much care they give sick patients. And then almost as quickly and easily, they decided to replace it with this thing called “global payments.”

LESLIE KIRWAN: The fact that this group so quickly came to that conclusion makes me very confident that this is the right model.

Leslie Kirwan is one of the payment commission co-chairs. As Secretary of Administration and Finance, she would be one of the key figures trying to translate the commission’s plans into action.

KIRWAN: There’s no doubt that the fact that we’ve all pointed to global payments as the way of the future is easy as compared to charting a thoughtful, workable transition for how to get there.
Read more…

Fueled by ideology or misunderstanding, a virtual cottage industry of skeptics has arisen around Massachusetts’ landmark health reform law. And perhaps the favorite issue of the critics is the contention that the reform is unaffordable and will break the bank.

The Taxpayers Foundation has released a new report which debunks this myth. The analysis concludes that the public cost of achieving near universal access has been modest and well within early projections of how much the state would have to spend to implement the reform.

Based on actual and projected spending data for the first four years of health care reform, the Foundation concludes that state budget spending on health reform has grown from a base of $1.041 billion in fiscal 2006 to a projected $1.748 billion in fiscal 2010. That is an increase of $707 million, half of which is supported by federal reimbursements. The $353 million state share translates into an average yearly increase of only $88 million.

The analysis found that new spending for Commonwealth Care and MassHealth was largely offset by decreases in uncompensated care pool payments and in supplemental payments to Medicaid managed care organizations.

Fears that the initial rapid enrollment in Commonwealth Care would continue unabated never materialized. Read more…

It’s perhaps one of the most puzzling conundrums: Massachusetts is known worldwide as a center for health care excellence, yet appointments with primary care physicians take months to schedule.

According to a national survey released last week, the average wait time for patients seeking appointments with family practice physicians in the greater Boston area was 63 days – one of the longest in the nation. This number is troublesome, particularly at a time when thousands of newly insured residents will further increase demand.

Primary care clinicians are critical in creating health access, keeping quality of care high and costs low. As Massachusetts and the rest of the country face both a primary care physician shortage and a developing national health reform agenda, we need a larger effort designed to increase physician recruitment. Read more…

This report from the Massachusetts Taxpayers Foundation aims to revise one of those media “truths” that takes on a life all its own. Here’s the overview:

Three years after Massachusetts enacted its groundbreaking health care reform law, Chapter 58 of the Acts of 2006, the number of residents with health insurance has increased by more than 432,000, giving the Commonwealth by far the lowest rate of uninsured residents in the nation.

An analysis by the Massachusetts Taxpayers Foundation finds that the cost of this achievement has been relatively modest and well within early projections of how much the state would have to spend to implement reform.

Based on actual and projected spending data for the first four years of health care reform, the Foundation concludes that state budget spending on health reform has grown from a base of $1.041 billion in fiscal 2006 to a projected $1.748 billion in fiscal 2010. That is an increase of $707 million, half of which is supported by federal reimbursements. The $353 million state share translates into an average yearly increase of only $88 million.

The full report is here.

The rising cost of health insurance is a problem for everyone but it’s a particularly difficult problem for the state’s fiscally strapped cities and towns where the cost of health insurance has risen at particularly rapid rates. Many local officials contend that the problem is that unlike most private insurers or the state, local governments have to get local unions to agree to virtually any change in that community’s health insurance plans.

What could localities do if they had more flexibility to design health insurance plans for their workers and retirees? Part of the answer might be found in Springfield Financial Control Board’s aggressive efforts to control increases in that city’s health insurance costs over the past few years, which included joining the state’s Group Insurance Commission (GIC), an option now open to the state’s other cities and towns but only if virtually all the public-sector unions in a community agree to the change.

In a study released last week by the Collins Center at UMass Boston’s McCormack School and the Rappaport Institute at Harvard’s Kennedy School, Robert Carey, an expert on Massachusetts health insurance costs, concludes that Springfield’s experiences offers three important lessons to local and state officials.

First, joining the state’s Group Insurance Commission not only saved Springfield between $14 and $18 million in the first two years it also did so in ways that gave the city’s employees and retirees lower premiums, reduced out-of-pocket expenses, and a broader choice of plans. Read more…

“They also will answer, ‘Lord, when did we see you hungry or thirsty or a stranger or needing clothes or sick or in prison, and did not help you?’ “He will reply, ‘I tell you the truth, whatever you did not do for one of the least of these, you did not do for me.’ “Then they will go away to eternal punishment, but the righteous to eternal life.” Matthew 25:44-46 (New International Version)

Jesus teaches us in the passage above that the quality of one’s character and faithfulness is measured by how one treats the “least of these.” I might add that the character of our Commonwealth is measured, not by how we treat the hungry, sick, imprisoned, stranger (i.e. immigrant), homeless, elderly – the “least of these” during times of budget surplus, but rather how we treat them during times of scarcity. Who is expendable? Who do we delete from the budget, without a whimper?

Surely this is the test that our State senate is facing at this very moment. A few days ago, this august body of dedicated individuals released a State budget that threatens disastrous consequences for the “least of these” throughout our Commonwealth. Read more…