As the presidential campaign enters its next phase, the economy, health care, and the war in Iraq continue as the three big issues facing the country and driving campaign themes.

When the topic turns to access to health care, we should prepare ourselves to hear Massachusetts’ efforts for health care reform referenced as either visionary or as a cautionary tale of misguided public policy. While I continue to be unwavering in my support of health care reform, the true answer on its success is really yet to come.

In order to succeed, what we must do next is grapple with health care costs in a manner that hasn’t been done before. Massachusetts is the perfect laboratory in which to create real change.

The good news is that people are seizing the moment. Last week in this blog, Secretary of Health and Human Services Dr. JudyAnn Bigby wrote “that we must promote policies that ensure people have the right care in the right place.” I and others have said the same thing. It is my hope that the Commonwealth’s Quality and Cost Council, the Massachusetts Association of Health Plans and the provider community will leverage their common goals for the greater good. Read more…

Nancy Turnbull’s year-end entry was a thought-provoking way to start the new year and as a result, generated some good discussion about health care costs and containment strategies. It is a conversation whose time has come.

The Massachusetts Association of Health Plans (MAHP) released in December a package of legislative proposals and voluntary measures its member health plans will adopt, including public disclosure of health care revenues and expenses, to help consumers and employers understand where the money is going in health care. Also in December, the Commonwealth released its Healthy Massachusetts Compact, a similar plan, which builds upon five elements to achieve its goals of ensuring access to health care; advancing health care quality; containing costs; promoting individual wellness; and promoting healthy communities.

What excites me is that health care reform has created an unprecedented opportunity—and desire—among different but related groups, all of whom have a role to play in keeping health care costs as affordable as possible. This groundswell is moving us all toward a common goal. Read more…

Earlier this week, The New York Times published an article that rightly laid out the challenges of government mandating insurance coverage to its citizens. I agree with the comments made by Diane Rowland, executive vice president of the Henry J. Kaiser Family Foundation, a non-partisan organization that focuses on health care policy analysis and large-scale public heath information. She said “that an individual mandate is the only alternative to government provision of coverage if you hope to achieve universal coverage.”

Universal coverage has been the goal of Massachusetts’ health care reform efforts from the very beginning. Our experience is reflective of a profound social revolution with the fits and starts of any worthwhile, ambitious undertaking. Right now, we in Massachusetts are at the first real critical juncture of the implementation of health care reform: having our citizens enrolled by year’s end, before they suffer a financial penalty. The good news is that Commonwealth Health Insurance Connector Authority claims that enrollment is exceeding expectations. Health plans such as Tufts Health Plan want to make it as easy as possible for people to enroll, and as a result, Tufts Health Plan is suspending usual operational requirements so that any individual who enrolls with us through our individual channel by Dec. 31 will be covered and thus, able to avoid the 2007 penalty.

The bad news is that for many, health insurance continues to be a “grudge purchase,” with people hedging their bets that illness won’t strike or accidents won’t happen. Read more…

I have enjoyed reading this forum for the past several months as there has been interesting, provocative and intelligent commentary on the early implementation of health care reform.

Let’s face it, though—most of the contributors and the readers are actively engaged in the political process, delivery of health care and/or health care coverage, and know full well that the Dec. 31 deadline for coverage is looming. But as John McDonough, executive director for Health Care for All, has recently pointed out in this forum, there is a tremendous need for education aimed at the working person who is barely aware of his or her responsibilities under health care reform. Moreover, there is even less awareness of the penalties that go into effect on January 1, for those who do not sign up for health insurance. November and December provide us with a unique teachable moment. We all—the Connector, providers, health plans, advocates and communities—must join with the media to raise people’s consciousness.

The Department of Revenue intends to highlight the issue when tax forms go out in January. That’s too late for people to avoid the penalty. In fact, enrollment by November 15 for a December 1 effective date is necessary to avoid the penalty. The legislature should permit enrollment effective January 1, to satisfy the mandate. Read more…

When people debate the merits of health care delivery systems, it isn’t the quality that is in question, though it should be part of the discussion. Rather, in large part, it is the cost of insurance coverage that fuels the debate. As the CEO of a not-for-profit health care plan, I can tell you firsthand as one who oversees the coverage of more than 650,000 members, and as an employer, whose company’s health care costs were in the neighborhood of $15 million last year, keeping health care as affordable as possible is something I think about a great deal. So I thought it would be constructive to share with you the break down of how premium dollars are spent.

Overwhelmingly, health insurance premiums pay for the cost of medical care and other services that benefit members. That’s appropriate and why one has insurance in the first place.

According to information compiled by the Massachusetts Association of Health Plans, in our state, medical expenses account for 87 percent of the health care dollar. That includes hospital services, physician care, other health professionals, medical devices and other medical services, and prescription drugs.

Ten percent goes towards administrative cost, which includes care management programs for individuals with chronic conditions, functions such as claims processing, consumer and provider support, marketing, compliance with government laws and regulations, and other activities that support health plan operations.

Among not-for-profit plans, administrative costs also include reinvestment of funds into strategic initiatives designed to control costs and improve members’ health. Read more…

Here we are in late July and the question is being asked with greater urgency, “Is health care reform going to be successful?” I believe the short answer is “yes.” The only folks I hear saying that it is not working are from other states, and tend to be opponents of the model agreed to by all the stakeholders in Massachusetts. I am confident that in a few years’ time, we will look back with pride on what was accomplished when we all came together to support life changing public policy. But as this is a process that is happening in real time, it will continue to evolve and be affected by both politics and the marketplace.

A perfect example of proposed legislation that could have profound implications on health care reform is Senate Bill 697, which calls for standardized coding, a numerical method used by health plans to define medical treatments for billing purposes. At first glance, this certainly appears reasonable. Who wouldn’t support a national coding system that is already used by hospitals for Medicare?

However, the reality is that this is much more complex than a quick glance would indicate, with major ramifications on payment policy and premiums. In brief, the scope of technology changes necessary would require the resource investment of tens, possibly hundreds, of millions of dollars to support either reconfiguring existing technology systems or purchasing new systems.

While Massachusetts’ not-for-profit health plans currently have the lowest administrative costs in the nation, it is no leap to assume that if S.697 passed in its current form, health care costs would increase, and ultimately undermine the goals of health care reform by raising premiums for all consumers, including those who are just now benefiting from coverage. My colleague, Eric Schultz, president and chief executive officer of Fallon Community Health Plan, told the State House News Service that the bill would “do a lot of harm in dismantling health care processes.” He was not overstating the issue.

It wasn’t that long ago when hospitals and health plans were brought together by the Massachusetts Health Data Consortium to discuss the technical solutions necessary for the Health Insurance Portability and Accountability Act of 1996. The outcome of that collaboration is simplified administrative processes, which translate into reduced costs for health plans, providers, and members.

But there is always room for improvement. To that end, it is my recommendation, which has the support of the Massachusetts Association of Health Plans, that hospitals and health plans reconvene with the Massachusetts Health Data Consortium to find common ground on this complicated and expensive, though well-intentioned bill. No one wants to see the gains we’ve recently achieved with health care reform become once again out of reach.

James Roosevelt, Jr. is the President and CEO of Tufts Health Plan

A little more than a year ago, I read an interesting article in the Wall Street Journal about the Anabaptists negotiating discounts for medical care. As Mennonites, these “plain people” as they call themselves, do not join systems like Medicare or employer-sponsored health care coverage. The main focus of the article was that the Mennonite community had joined forces with the local hospital and successfully negotiated reduced fees.

There was a secondary point in the article that struck me. Read more…

Today is the first day that an individual in Massachusetts can purchase a new Connector approved health plan. It is a date that came quickly. The bottom line to the successful implementation of health care reform is education. An understanding of health care reform and its implications needs to be fostered as there are individual consequences.

Educating the public about a major change in public policy is not an easy feat. While Nancy Turnbull made me laugh with her suggestions for “seals of approval,” she is on to something. Many reports and my own conversations confirm that many are unaware of the individual mandate to purchase insurance. While the issue of affordability has prevented some from accessing coverage, persuading those that make a deliberate choice not to purchase coverage presents an additional challenge beyond simple education. We – meaning all of us in health care – need to engage the public and ensure that the individuals and families who will now be able to purchase health insurance understand their coverage options, the benefits and the costs of that coverage.

Our history in the United States of providing social safety nets, which dates from colonial times, has shown that these programs evolve as times change and start with a massive need for information. In 1938, the Woolworth Company used a sample social security card to demonstrate how a card would fit in one of their wallets. Read more…

Earlier this week, I participated in a panel discussion that talked about the results of a survey on how consumers make health care decisions. It was an interesting discussion on how we can have more transparency in health care and which health care information individuals may find useful.

We – meaning those of us who work and have worked for many years in health care – tend to develop terms to represent a new movement or idea. In this case, transparency is the concept of sharing information on the performance of hospitals and doctors. Transparency is the answer to the questions of exactly how well the hospitals and doctors that care for us – often at some of our most vulnerable moments – perform their work.

The survey results had some interesting findings: Read more…

Gov. Deval Patrick’s announcement this past weekend that seven health plans will be submitted to receive a seal of approval from the Connector was momentous. Read more…