Transparency - Why It’s Important…
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The MA health care reform plan has gotten a lot of attention for its commitment to expanding coverage to those folks in Massachusetts who don’t have health insurance. And it’s off to a pretty good start. About 100,000 people have been enrolled in Commonwealth Care, which provides comprehensive, mostly free or heavily discounted health care coverage to MA residents who earn below 300 percent of the poverty level.
What hasn’t got much attention are the sections of the new legislation that are designed to make health care costs and health care quality more transparent and more understandable - thereby engaging us all in a conversation about what we can and should do about rising health care costs and uneven quality. This is important. If you ask people what’s wrong with health care, they’ll mention the uninsured - but they’ll start by talking about health care costs. But if you pry into that question - and ask them why it’s so expensive, you’ll get as many answers as you have answerers. There is simply no consensus - no source of truth - on why health care costs are high, or what’s driving them up. This is a problem. You can’t solve the problem of rising health care costs if no one has any idea about why health care’s expensive, or what’s driving the costs upward.
Transparency - the collection, aggregation and public distribution of information on health care cost and quality - is a big part of moving this issue forward. The new law creates a Health Care Quality and Cost Council, and gives it the authority to collect cost and quality data from health care plans and providers. The Council can then make that data available to the public - the same way Governor Patrick has simplified the state budget and made it available to the public through the state’s web site - and the discussion can begin.
For example, hospital costs for the same procedure - with the same degree of difficulty - vary by as much as 300 percent per procedure in Massachusetts. In other words, the same community hospital delivering the same service with the same outcome as another community hospital can collect as much as 3 times the money as another one collects. And teaching hospitals doing the same thing with the same outcome as a good community hospital can collect as much as 4 times what the community hospital collects. This is real big money - hundreds of millions, if not billions of dollars in differences over the course of a year.
It is only by publishing this information and engaging in the debate that we will ever be able to make any serious progress on bringing the cost beast in health care to its knees. Without this information - and without public access to this information - we’re all just stumbling around in the dark - with our own opinions about what’s going on with health care cost and quality - and no place to go to find real information about what’s actually driving up the cost of health care.
Let’s hope this part of health care reform gets the same attention in the months ahead as the more visible efforts to increase coverage and expand access.
To what extent are health insurers standing in the way of disclosing actual reimbursement rates paid to doctors, hospitals and other providers? Are there confidentiality agreements that prohibit disclosure? If the actual reimbursement rate is disclosed on the EOB after services are rendered, why can’t that information be made available to consumers before services are provided?
It would be even more valuable if referring doctors had this information easily accessible to them so they would be better able to refer their patients to the most cost-effective providers.
Finally, what, if anything, are insurers doing to simplify their offerings? If you have ten different plans that all cover a given service, shouldn’t you pay the same provider the same price for the same service no matter which of your plans the patient happens to have?
As a family that has been consistantly abused by Mass Health and the insanity of that program in it’s dealings with both patients and providers, I can attest that this health care reform scares me to death. When it was just the weak, disabled, and poor… populations that didn’t speak up for fear of being cut from the program, Mass Health could do whatever it wanted knowing that there would be no repercussions. And for years there were none as they arbitrarily changed their formularies, refused to cover common procedures, decided that asthma and allergies weren’t medical problems, etc. Never mind trying to deal with their mental health providers. Total nightmare.
But now many more unsuspecting people are going to be covered by this agency which is outdated, run by incredibly uncaring people and managed by workers that will out and out lie to it’s customers time and time again. This is going to be a nightmare unless Governor Patrick instills some order in Revere and determines that Mass Health needs to stop being a maverick agency run without any overseers and to be a caring agency providing health care for the people that need it.
PLUS, and this is a huge plus, as long as Mass Health bases it’s availablilty on the federal poverty guidelines without any cost adjustment for cost of living in an area like Boston, it’s worthless. For a family of 3 living on under 30K to be ineligible for healthcare is downright idiotic. Using the federal poverty guidelines that haven’t been updated in scores of years not only keep the needy off the roles, it also disallows them to get mandated healthcare so they are penalized by the commonwealth. And where’s the sense in that?
Mr. Baker, can you explain to me why my doctor, who, I know, is watching out for me and my best interest when prescribing medication, is constantly being visited by gorgeous , I mean smokin’, young female sales and marketing types employed by drug companies. On many occassions they bring lunch for the office. And let’s not forget the paid for trips to conferences.
I don’t get it. Why does treatment need to be marketed like this to doctors who have a duty only to their patiernts. Surely these practices drive up the cost of medical treatment.
Question: what can health insurer’s like your’s do to stop these duplicities?
BC - Good question. Surprisingly, neither the health plan community nor the provider community is of one mind about this. There are plans that think this data should be in the public domain now, and there are plans that think this is the end of the world. Same goes for the providers. There are confidentiality agreements attached to most plan/provider agreements, but as you point out, the information’s there on the Explanation of Benefit (EOB) form for all to see. What’s been happening in the meantime is the following: Some plans are making either general cost data (HPHC) or very specific data (Aetna) available on their web site to their members for specific services and specific providers. Some states are building cost databases that make a lot of this information available to their citizens (check out the NH DOI’s web site - I don’t know yet how to just give you the link - they’ve got a ton of information on cost available for their citizens - an initiative, by the way, we supported), and some providers (Dartmouth-Hitchcock up at Dartmouth is a good example) are making a lot of quality, service and cost data available to their patients. There are also private web sites - Health Grades, Web MD, Subimo, and the like, that are putting up a lot of cost and quality information as well.
And I agree with you completely about docs appreciating this information. In fact, most of the hits on the MA site - which is available through the Division of Health Care Policy and Finance - come from docs, and I’m told it’s to either check out their own performance, or the performance of their institution - on certain procedures, or to see how often a procedure is performed by someone they might be referring a patient to. People talk all the time about the value of public information on cost and quality to the consumer. Sure - that’s helpful - but I think the biggest winner under that scenario will be the provider, who will have far more information to make decisions with than he or she has now.
On the ten different plans/ten different payments for the same service from the same provider, I guess I’d say that there might have been some truth to this ten years ago, but today - most of the time - the same service from the same provider paid for by Harvard Pilgrim usually prices at the same price. There are some differences between HMOs and PPOs (although not within HMOs or PPOs), and sometimes there are differences between fully insured and self-insured members - but those differences are usually driven by provider interests and expectations. Most of the time - believe it or not - Harvard Pilgrim would prefer one rate of payment for the same service, not multiple ones.
Margalit - I used to know a lot about MassHealth when I worked for Health and Human Services and Adminstration and Finance. My knowledge these days is pretty spotty. I would assume that significant problems with MassHealth can be referred to the Office of Patient Protection at the MA Department of Public Health.
BC - what’s more important to you as a healthcare consumer, the price or the quality? Transparency as it relates to quality will allow patients (as consumers) to select wisely. Transparency in cost tied to quality is also fair game in my eyes. While Mr. Baker points out that most provider agreements include confidentiality language, word does get out within certain circles wither through EOBs or through locker room talk amongst providers. The challenge is getting our hands around the right data to support quality and the reimbursement tied to it. When everyone’s pulling on the same ore, we’ll all benefit from such a system.
MPD – Both price and quality are important. While I would like to have robust price and quality transparency tools at my disposal, I think it would be even more useful if doctors who make a lot of referrals had them in order be better able to steer their patients to the most cost-effective providers. There are also different issues depending on what is needed.
For example, if my doctor prescribes a drug for a condition I have, I hope he took cost into account and prescribed a generic if one is available. It should be relatively easy for me to find the local drug store that can supply it at the lowest price as my insurance plan has a percentage of the cost co-pay (except for mail order). If I need an MRI or other imaging, it would be helpful to know which local imaging facility will do the procedure for the lowest cost. If I need to enter a hospital as an inpatient, I would like to know about infection rates, quality of the nursing, etc. as well as the case rate or per diem cost for the stay. If I need surgery, some data that speaks to the surgeon’s competence including how many times he has done this particular surgery and what his outcome statistics are. If I need sophisticated care like cardiac bypass surgery, neurosurgery, back surgery, cancer treatment, or an organ transplant, I would probably prefer to be treated at a center of excellence by an experienced surgeon with good outcomes and would be less concerned about the price. If I need my gall bladder removed, a decent general surgeon operating at a community hospital for a reasonable price would probably be fine.
I appreciate Charlie Baker’s detailed response to my questions. I hope both insurers and providers can get on the same page soon and realize the importance of price and quality transparency tools for both patients and doctors.
What measures will the Health Care Quality and Cost Council use for quality, and are these measures going to take into account the prior health statuses of patients, subsequent changes in health status, and the risks associated with caring for sicker patients that some hospitals take and others avoid? Transparency seems to carry great potential as a tool for informing patient and physician decisions and reducing costs, but its value depends heavily on the meaningfulness of its measures.
Apollo - the answer is mostly, “yes,” although there’s always some debate about how easily any of this can be controlled for and properly measured. Some of the measures that are being considered currently aren’t too hard to reach agreement on with regard to accuracy, etc. For example, hospital acquired infections is mostly about the way it’s measured, and I suspect that can be agreed upon pretty easily. There’s also talk about other measures that are already measured and collected, but not made publicly available. That’s a distribution issue, not a debate over the collection and measurement process.
The Council is chaired by EOHHS Secretary Judy Bigby. You should consider either asking her directly, and asking her office for information on the Quality Subcommittee. Their meeting’s are open to the public.