My entry today picks up on the issue raised by Secretary Kirwan at the end of her recent post, in the hope of generating some informed exchange on the issue of cost containment. No one disputes the imperative of bringing health care spending under control; this is necessary for the continued viability of both the Chapter 58 coverage expansions and the U.S. health care system overall.
How do we do it? To be sure, cost containment is not an issue that has been ignored until now; many recent innovations in health care delivery and financing have this explicit goal. But let me offer these two pieces of information and then pose some questions:
1. At the annual meeting of the Health Care Quality and Cost Council last Friday, Stuart Altman presented a list of techniques for limiting growth in health spending, in ascending order (by his estimation) of impact:
Very limited impact
• Encourage greater use of preventive services
Limited impact
• Provide better price and quality information
• Require patients to pay more
• Restrict use of harmful care
• Create a governmental “high cost reinsurance system” with effective case management for chronic conditions
• Reduce expense and waste of medical malpractice system
• Pay-for-performance reimbursement
Greater impact
• Restructure delivery system (integrated care)
• Develop government programs to conduct “comparative effectiveness studies”
• Restrict use of marginally useful care
• Limit supply of expensive services
Greatest potential
• Regulate payments to providers
• Establish global budgets
2. Elliot Fisher, a professor at Dartmouth Medical School and expert in the study of regional variations in health care practice and spending for which the Dartmouth Atlas is nationally known, spoke to the Quality and Cost Council in June. (A version of the talk, presented to the Massachusetts Medical Society last fall, can be found here.) Dr. Fisher offered these conclusions from his research:
• Higher spending across regions and physician groups is largely due to overuse of supply-sensitive services – hospital and ICU stays, MD visits, specialist consults; and more is worse.
• Overuse is largely a consequence of reasonable differences in clinical judgment (not errors) that arise in response to local organizational attributes (capacity, clinical culture) and state/national policies promoting growth and more care.
• Improving efficiency will require fostering local organizational accountability for the longitudinal costs and quality of care. Performance measurement, public reporting, payment reform and technical assistance should be aligned toward this goal.
Provocative views from respected and influential thinkers, which raise for me these questions: Are we doing enough to harness spending growth? Need we move to policy remedies (public and private) further down Prof. Altman’s list? Should we look at how “supply-sensitive services” are supplied in Massachusetts, and consider reducing oversupply for the sake of both cost and quality, as Dr. Fisher’s findings suggest? Based on the best evidence we have, how should the roles of government and the market be balanced to best control spending, a goal that all agree is essential? And how can we move the body politic in that direction?
Everybody talks about the weather, but no one does anything about it. Many things are being done about health care spending; will they be more effective than trying to stop the rain from falling?
Robert Seifert is Executive Director of the Massachusetts Medicaid Policy Institute
(note from admin. – this is a serious subject which I hope you’ll all dig into…but in the meantime…what song pops into your head with Bob’s last line?)
Thanks Bob for this valuable post.
Cost control is clearly the next challenge facing the Commonwealth. The important work of the Quality and Cost Council is just the start; our political leadership at all levels must embrace serious cost control, just as they took risks to expand access in chapter 58.
Health Care For All has drafted cost control legislation introduced by Senator Montigny and Representative Marzilli. The bill puts a number of ideas on the table that go beyond some of the easy measures usually talked about. The bill includes provisions to:
• Change financial incentives to reward hospitals for preventing unnecessary readmissions and avoidable complications.
• Empower and train individuals with chronic disease to improve their health and well-being by engaging in evidence-based behavioral self improvement programs.
• Curb pharmaceutical industry marketing practices.
• Remove barriers to expansion of the Senior Care Options (SCO) program to effectively manage care for “dual eligible” seniors – seniors in Medicaid and Medicare and promote effective Safety Net Plans for under age-65 dual eligibles with disabilities.
• Reduce hospital emergency department overcrowding and diversions by using improve patient flow management.
• Establish prospective payment reimbursement for providers of outpatient services.
• Require the Division of Insurance to hold public hearings when individual and small group premium increases exceed seven percent in any given year
The bill will be heard before the Health Care Financing Committee next week, on October 4. You can read a brief fact sheet here, and a detailed report explaining the provisions of the bill here.
This represents an opportunity to advance the critical substantive conversation on cost control.
Time for some truth telling. Not just more blah blah blah cheerleading that doesn’t address the real problems causing this healthcare mess.
“…Greater impact
• Restructure delivery system (integrated care)
• Develop government programs to conduct “comparative effectiveness studies”
• Restrict use of marginally useful care
• Limit supply of expensive services
Greatest potential
• Regulate payments to providers
• Establish global budgets”
Can somebody tell us why the “advocates” and “policy experts” are not fighting like hell for the best policies and actions to be the leading edge of reform?
Is it because these sensible reforms would require putting regular people and communities before insurance companies and physician/hospital trade groups that give money to politicians?
Is this why the individual mandate to purchase private insurance is at the leading edge of the state’s best attempt at health system reform, followed by increased reimbursements to physicians and hospitals?
Can someone tell us, the public, who pays the salaries of Mr Siefert and Mr Rosman, the “experts” in policy and consumer advocacy?
I have been informed that a large portion of that money comes from the state’s largest private health insurance company, Blue Cross and Blue Shield.
I guess that would help explain a few things, sadly…
It looks like it’s gonna be up to us regular people to shed some light on what’s really going on here and to demand a stop to it.
Follow the money trail. Ask yourself who wins and who loses as you follow the flow of dollars that would occur with each cost control reform policy listed by Mr Altman. To learn more about sensible health reform that puts people’s health and cost control at the leading edge go to http://www.masscare.org/about
Then dial 617-722-2000 and tell the governor and your legislators what reform you think would be best for you, your family and your community – and drop a note to your local paper while you’re at it.
The above response, attacking Mr Rosman and Mr. Seifert, with phrases like “blah, blah, blah cheerleading”, derisively questioning their “expertise” and asking “who pays them” reflects a disturbing trend that has been surfacing in health care blogs. Blogs should be forums for generating serious discussions of issues, not a vehicle for personal attacks. Responsible public dialogue also demands self-control and appropriate discourse.
Mr. Joffe-Halpern,
I agree that personal attacks are unnecessary, but I do believe that you and the other architects of this grand scheme have effectively painted the targets on your own backs. Perhaps you folks are so isolated and insulated that you can not feel the palpable anger among the citizens who believe that they have been sold out to the insurance industry by their elected officials. I, and many others, fail to see how consumers, who were left out of the loop when this whole fiasco was crafted, are benefiting in any way from Chapter 58. Additionally there has been a tremendous amount of obfuscation regarding the successes attributable this “reform”, and the dark side of the legislation. Many of us feel that the law represents nothing more than a cosmetic approach to a real problem. The backlash is just beginning. Frankly, sirs, if you folks can not stand the heat, get out of our wallets!
“Responsible public dialogue also demands self-control and appropriate discourse”
Gee, pardon me, I thought the priority here was talking honestly about the issues. Sometimes that may involve talking honestly about certain individuals who are in influential positions to have a direct impact on the issues.
People have to start being held responsible for their actions. ie Are you with the monied intersts or with the needs of ordinary people? Think carefully because you will be judged and called out to account for your actions. Maybe the good Rev Hamilton can post about this theme.
In closing, re “a disturbing trend that has been surfacing in health care blogs”
Did you ever stop to think that maybe this anger is because thousands of people are suffering and dying – FROM PREVENTABLE AND TREATABLE PROBLEMS — because of our perverted healthcare system and many are being bankrupted????
It is time for everyone to stand up and be counted for which side you are on. If you will not step forward on your own than others will assist you.
—
p.s. To clarify, these items on Mr Altman’s list are indeed positive reforms and should be undertaken IMMEDIATELY
“…Greater impact
• Restructure delivery system (integrated care)
• Develop government programs to conduct “comparative effectiveness studies”
• Restrict use of marginally useful care
• Limit supply of expensive services
Greatest potential
• Regulate payments to providers
• Establish global budgets”
Can somebody tell us why the “advocates” and “policy experts” are not fighting like hell for the best policies and actions to be the leading edge of reform?
• Restructure delivery system (integrated care)
• Develop government programs to conduct “comparative effectiveness studies”
• Restrict use of marginally useful care
• Limit supply of expensive services
Greatest potential
• Regulate payments to providers
• Establish global budgets”
[...] This new research reinforces a larger body of work documenting the inefficient overuse of certain services and calling for better alignment of incentives and local delivery system accountability for the cost and quality of care. (I’ve written about some of Fisher’s contributions before here.) [...]