Comments on: Transparency - Why It’s Important…

By: Charlie Baker

Charlie Baker — Mon, 16 Apr 2007 22:08:29 +0000

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.

By: Apollo

Apollo — Sat, 14 Apr 2007 15:53:05 +0000

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.

By: BC

BC — Fri, 13 Apr 2007 23:31:57 +0000

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.

By: MPD

MPD — Fri, 13 Apr 2007 02:10:31 +0000

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.

By: Charlie Baker

Charlie Baker — Thu, 12 Apr 2007 21:16:54 +0000

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.

By: Ernie Boch, III

Ernie Boch, III — Tue, 10 Apr 2007 17:12:10 +0000

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?

By: margalit

margalit — Tue, 10 Apr 2007 04:25:17 +0000

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?

By: BC

BC — Mon, 09 Apr 2007 23:39:37 +0000

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?