Cost, Quality and Access: The Challenging Journey Continues

Today the Mass Medical Society (MMS) hosted its ninth annual State of the State’s Health Care forum, focusing on the impact of rising costs on the practice of medicine and access to care.

EOHHS Secretary JudyAnn Bigby opened the program with an overview of Massachusetts’ status on access, cost, hospital and insurer financial performance, long term care, healthcare workforce, quality, and disparities.

• Access: Massachusetts has made significant progress in decreasing the number of uninsured since the inception of health reform. Sec. Bigby used statistics from recent DHCFP, Urban Institute and Census reports to illustrate this point.
• Cost: More affordable health insurance options are available to individuals and families as a result of health reform.
• Financial Performance: As of March 2008, insurers, hospitals, and community health centers show positive financial performance (taking into account days in reserve, profit margins, expenses).
• Long term care: An increasing portion of long-term care spending is going to community-based programs, but nursing homes still account for the majority of LTC spending.
• Disparities: There are widespread racial and ethnic disparities in all regions of the Commonwealth. Despite health reform’s success in increasing access, Hispanic and Black residents have higher rates of uninsurance when compared to other races and ethnicities.

Next up was Susan Dentzer, Editor-in-Chief of Health Affairs, who advocated for rationalizing health care spending.on both the state and national level. She sees health care costs threatening the gains made in Massachusetts health reform, and wonders if initiatives to control costs (like Chapter 305) should have happened simultaneously with efforts to increase access. Ms. Dentzer also explored national health spending trends, highlighting that national health expenditures grow at about a 2% faster rate than the gross domestic product. This is unsustainable. What drives the growth in health care spending? Susan Dentzer identifies technology, health status (e.g. increasing rates of obesity), lack of competition, fee-for-service payment structure, and inefficiency. Phew!

What can we do to slow costs? The Dartmouth Institute and the Commonwealth Fund recommend the following:

• Promote health information technology
• Do comparative effectiveness research
• Include the patient in decision-making
• Promote health and disease prevention and management
• Realign incentives to encourage quality and efficiency (e.g. pay-for-performance)
• Increase price transparency
• Institute a patient-centered medical home

Following Ms. Dentzer, Dr. Elliott Fisher from the Dartmouth Institute for Health Policy and Clinical Practice, also focused on the need to slow health care costs while increasing quality. Dr. Fisher looked at regional variations in health spending. According to Dr. Fisher, the more we spend on health care the worse the outcomes, which should encourage regions to adopt conservative spending practices, but doesn’t. The current payment system rewards quantity rather than quality.

So, what does the health care system need? Dr. Fisher recommends the following:

• Promote health information technology
• Foster accountable care organizations that provide and manage a continuum of care. Potential accountable care organizations include integrated delivery systems, physician-hospital organizations, and regional collaboratives.
• Use meaningful measures to measure performance: effectiveness (health outcomes over time), care coordination (did care meet patient/family needs?), total per-capita costs.
• Institute payment reform: reward value, not volume; establish a shared savings model.

The last portion of the program included a panel discussion on health care quality with Secretary Bigby, Dr. Bruce Auerbach, Donna Cupelo (Verizon), Susan Dentzer, Elliot Fisher, Cleve Killingsworth (BCBS), and Paul Levy (BIDMC). Dr. Auerbach opened up with a statement that physicians have a responsibility to both their patients and the health care system to work with other stakeholders to improve quality of care. Cleve Killingsworth, CEO of Blue Cross Blue Shield of MA, responded by saying that the health care system doesn’t let health care providers give the care they want to give. He sees health care costs increasing every year, and many people still can’t afford the care they need. BCBS is committed to tightening its care management programs to try to eliminate over- and under-use of care. He called on physicians to take the lead on quality.

Next, Donna Cupelo, New England Region President for Verizon, said that business is a player in the health reform debate, and not only employers but also employees are feeling the impact of rising health care costs. She advocates for giving consumers more choice, and is supportive of a national model that has one rule on health insurance standards rather than many different rules. Finally, Paul Levy from BIDMC stated that improvement in the health quality and cost arenas des not happen without public disclosure of clinical results. Like many other presenters today, he also criticized the pricing and payment systems. Why do different institutions receive different compensation for the same thing? He also said that we need to do something about duplicative care and the use of expensive technologies. All this – he states – needs to happen now, and challenged the state and insurers (Sec. Bigby and Cleve Killingsworth were sitting next to him) to do join him in taking action on the cost and quality issues.
Suzanne Curry