Bit by bit over the past two months or so, the conversation about health care reform has shifted. While there are still complex coverage issues to consider and resolve, public and private health leaders are increasingly focused on the law’s sustainability, which requires us to focus on the growth of health care costs in Massachusetts.

Consider the following examples from the last two weeks alone:

Paul Levy has posted to his blog a list of simple but provocative questions and answers about cost, attracting much discussion. Jon Kingsdale and Leslie Kirwin have both worried publicly about the impact of health costs on the state budget and the health care reform law. At the Quality and Cost Council’s annual meeting, Stuart Altman presented a number of interventions to slow the growth in health spending, arrayed on a spectrum from very limited impact to greatest potential impact. Writers from across the health care community have used the WBUR blog to talk about cost.

I have three small suggestions on this emerging cost conversation:

First, the discussion needs to move beyond the blogs and boardrooms to the broader public. Polls suggest that rising health costs are the public top health concern. Let’s discuss openly the tradeoffs that Stuart Altman outlined in his presentation. Read more…

There has been much focus in the health care reform debate on who pays for care – essentially, what is the optimal balance between government, employers, and individuals. But so far, we have paid little attention to how we pay for care.

Recent actions by state and federal government may shift the conversation. Medicare just announced that it will no longer pay for treatment of certain preventable hospital errors, injuries and infections. On October 1, MassHealth will launch a $74 million pay for performance program targeting health disparities and encouraging improvement in several specific areas of care. The state’s Group Insurance Commission is already using payment to reward cost-effective care.

These moves are part of a quiet revolution in health care, a movement toward using the payment system to influence the quality, safety, and effectiveness of care. As Lisa McGiffert, Consumers Union policy analyst, told the New York Times: “Medicare is using its clout to improve care and keep its patients safe.”

At Blue Cross, we are already seeing how changing the payment structure can support quality and safety improvements. Read more…

While debate continues on some aspects of our state’s health reform law, one issue inspires consensus: the need to control health costs in Massachusetts. The logic is simple: the law is based on creating subsidized and unsubsidized insurance coverage for the state’s uninsured. But if health care spending in Massachusetts continues to grow at about 10 percent each year, these new insurance products will quickly become unaffordable (for some they are unaffordable today). Sustaining our law requires directly facing the problem of health costs.

Dolores Mitchell and Bruce Bullen both discussed this issue, focusing on whether the public is ready to make cost-conscious choices in a more transparent system, and whether such choices will encourage providers to moderate their costs. These options must be pursued, but the most promising route to controlling costs is by making care better. Read more…

Here’s a great story about health care reform in action. Two weeks ago, a 63-year-old retiree walked into the offices of the Commonwealth Connector and became the first person in Massachusetts to purchase unsubsidized insurance coverage through the new organization. This man – let’s call him “Mr. P.” — retired early a few years ago, and purchased insurance under COBRA through his former employer. (COBRA is a federal program that gives individuals the option to continue health benefits provided by their employer or other group for limited periods of time under certain circumstances.) Now, his eligibility through COBRA is about to expire, and he will not qualify for Medicare benefits until he turns 65 two years from now. It’s just the kind of gap many people face at one time or another. Read more…

There is nothing like talking to an outsider to get some perspective on a public debate.

This past weekend, my family entertained a friend from New York. Although not in the health care field, my friend is interested in policy innovation and social change. (He works on public education reform.) He peppered me with questions about our health reform law. How is the state deciding who has to buy insurance? How is the public reacting? Is the political consensus holding? Read more…

For the past six months, local attention on the Massachusetts health reform law has focused – appropriately – on the complex and difficult decisions faced by the Commonwealth Health Insurance Connector Authority as we attempt to make coverage available to the half million state residents without health insurance. Blue Cross Blue Shield of Massachusetts – an original and vocal supporter of the reform movement – has participated actively in this public debate and will offer an array of new, innovative products to individuals and small businesses seeking coverage under the new law.

But the public focus on the Connector has obscured what should – over time – become an equally influential public body – the state’s new Quality and Cost Council. Read more…