Tag: Charlie Baker

Reducing Opioid Abuse, A Quick Guide to Internet Resources

The opioid crisis has been upon us for years now, and we are now seeing the problem become more pervasive, with more than 90 deaths per day in the U.S. due to this scourge. The president recently said he would be declaring a public health emergency (which would free up some funds) but has not done so as of this writing. The public health threat is so persistent that it calls for responses on many levels, and those responses are coming. Some have been in place for a while, some are more recent. These responses may be broken down into a number of different categories:

The overarching goal is to eliminate the use of opiates for all but the most critical short-term needs (limiting prescriptions to a seven-day supply) and medically-appropriate chronic and palliative pain management. There are alternative pain relief drugs — and a wide variety of other treatments for pain, ranging from TENS to meditation to VR.  Taken together, the initiatives highlighted and linked to above represent a good start. Of course, we need more than a good start, as the US consumes a wildly disproportionate share of opiates compared to other countries — follow link for some facts and figures — for predictable reasons of economics, politics and culture, and we are paying a staggering price in excess morbidity and mortality and in secondary effects (the effects on family and community).

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Musings on Payment Reform


Charlie Baker is the president and CEO of Harvard Pilgrim, a nonprofit health plan that covers more than 1 million New Englanders. Charlie is a regular contributor to THCB, where he has authored posts on national health reform (See: “Is Massachussetts a Model for National Reform?”  and related issues facing the healthcare sector. (For example: “Shifting Costs From Public To Private Payers“). His posts also appear at his own blog, Let’s Talk Health Care.

This week Charlie confirmed a longstanding rumor, announcing that he will be giving up his position at Harvard Pilgrim at the end of July to run as a GOP candidate for governor of Massachusetts. You’ll find more about his campaign on his web site,

The Commonwealth of Massachusetts – along with a number of other states (including New Hampshire and Maine) and the federal government – is kicking around a number of ideas concerning payment reform.  The argument goes something like this – since the current health care system, led by the gigantic Medicare program, pays primarily on a fee for service basis.  This “do something” payment model encourages clinicians and hospitals to do “more” for patients than they might do otherwise, if they weren’t encouraged to “do something” to get paid.  Add to that the fact that fee for service – again led by Medicare – pays more for new technology than it does for existing technology, and less for primary care, and you have the primary ingredients in the recipe that’s driven our system to be technologically driven, volume driven, fragmented and very expensive.

In Massachusetts, the group that’s working on payment reform seems to think the solution to this problem is to move everyone away from fee for service and into something that’s being called, “global budgets.”  Put simply, global budgets are a new and improved form of capitation.  Let me be clear on this one – I’m actually a big fan of both.  I believed in capitation when I worked in state government, and I worked for a medical practice (Harvard Vanguard Medical Associates) before I came to Harvard Pilgrim that was built on global budgets.

And before I go any further, I would offer up the cover story in this month’s issue of Health Leaders Magazine – titled “Bundling By Decree” as a solid a representation of the pros and cons of this debate as it winds its way through the national discussion around health care and payment reform.  This article is primarily about bundling payments around episodes of care, but the issues it raises – in both directions – apply in either context.

With that said, I wonder about whether or not global budgets, at least in the short term, are the answer to our health care cost and quality problems.  For some provider organizations, global budgets work – but they work in large part because those particular clinicians believe in them, and want to practice in environments that are based on them (like Harvard Vanguard/Atrius HealthCare).  But that represents a fairly small slice of the practicing clinician community – I’m guessing 10-15 percent.  Maybe 20.  It’s also not clear to me that this issue, above all else, drives our cost/quality problem, since many other countries that spend a lot less than we do on health care and have solid clinical results use fee for service payment systems too.

As far as I can tell, those other countries that spend less than us on health care do two things differently than we do.  First, they spend less on each service than we do – sometimes a lot less.  They also have robust primary care systems.  This, in particular, is just the opposite of our approach.  Our payment policies – and as a result, our medical education system – have been disinvesting in primary care for years.

In the short term, I’m not sure global budgets solve this disinvestment problem.  First of all, it’s financial and operational whiplash for a system that’s been running on fee for service for years.  That, all by itself, will take some getting used to.  It’s also not clear that Medicare or Medicaid – which make up 50-60 of the payments to providers to begin with – would also adopt global budgets.  If they don’t, having private sector payors using global budgets and the public sector payors using fee for service is just about  the worst outcome I can think of for providers and their patients.  The mixed messages these two payment models would send about what matters and what’s important would be virtually undecipherable.

This makes me wonder if our short term approach shouldn’t focus instead on changing the message all payors send under the current fee for service system to providers by improving the way we pay for primary care.  No one thinks we can possibly deliver integrated, coordinated care if we don’t send some signals to the medical and medical education community that primary care matters.  If a young medical student can make $250 an hour in primary care – or $1,000 an hour in dermatology – or $2-3,000 an hour in cardiology or orthopedics – how hard do you think it is to get that person into primary care?  The answer is it’s wicked hard – and the declining number of students going into primary care coming out medical school for the past decade is proof positive of that.  We used to be 50/50 primary care / specialty care.  Now we’re 70/30, and some of the anecdotal information suggests that kids coming out of U.S. medical schools are now running 15/85 primary care/specialty care.

Think about it.  No one disputes the fact that primary care has a key role to play in care management and care coordination – especially as the Baby Boomers get older.  The state’s Payment Reform Commission says global budgets will take three to five years to implement – and expects that every doctor will be using an EMR as one of its requirments for success.  Will this approach really grab today’s medical students and practicing clinicians and say – ”HEY!  It’s time to invest in primary care!”  In the short term, I think we’re more likely to get more capacity, faster, into primary care by boosting, on a relative basis, the fees paid to primary care providers by the private plans, Medicare and Medicaid.

Over time, maybe everybody gets to global budgets, but in the meantime, I think we need to do more to support primary care.

Is Massachusetts a model for national reform?

I get asked this question a lot these days, which shouldn’t be that surprising.  Harvard Pilgrim is headquartered in Massachusetts, and the Massachusetts health care reform plan is already a couple of years old.  More importantly, it has added about 440,000 people to the insured ranks (185,000 through unsubsidized private plans and another 255,000 through subsidized, Medicaid-like coverage), has maintained high employer participation (over 70%) and doesn’t appear to be crowding out private coverage as public coverage expands.

But my answer to this question remains “it depends.” There were profound differences between Massachusetts and the rest of the country before health care reform took center stage here that make relying on our experience somewhat challenging for the nation as a whole. For example, Massachusetts already had guaranteed-issue requirements for individual health insurance coverage even before reform. Today, most states don’t. So in Massachusetts, individual coverage was available to anyone who wanted to buy it, but it was really, really expensive.

That’s because most of the people who buy individual coverage — absent a mandate to purchase — usually plan to use health care services once they purchase the insurance. Insurance works through risk pooling – a small number of people who get sick spend the premiums paid by a much larger group of people who don’t.  If most of the people who buy the product plan to use it, there’s not enough healthy people to keep the overall price down.Continue reading…

Shifting costs from public to private payers

The other day, the American Hospital Association, the Blue Cross /
Blue Shield Association, Premera Blue Cross and America’s Health
Insurance Plans (FYI – HPHC is a member and I’m on the Board of
AHIP) released a joint study on public and private payment rates. 

study was prepared by Milliman, Inc., one of the nation’s most well
known number-crunching health care consulting firms. Readers of
this blog will not be surprised to learn that the study shows that
Medicare and Medicaid pay a lot less for health care services than the
Blue Cross and private health plans pay.  But I must say, even I was
a little surprised by the size of the differential.

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More on the 5 myths of U.S. health care

A good friend sent me a recent op-ed from the Washington Post that discussed the 5 myths of health care reform by Shannon Brownlee and Ezekiel Emanuel.

I’ve written about both of them before (here & here). Brownlee is a visiting scholar at the NIH’s Clinical
Center, and Emanuel is the chair of the Center’s Bioethics Department.
Ezekiel also happens to be the brother of incoming White House Chief of Staff Rahm
Emanuel’s. Hmmm…

Anyway, I really like most of what they have to say – which will
probably come as a surprise to them – and maybe to some of my
colleagues as well. Their five myths are, in no particular order…

1) America has the best health care in the world.

2) Somebody else is paying for your health insurance.

3) We would save a lot if we could cut the administrative waste of private insurance.

4) Health care reform is going to cost a bundle.

5) Americans aren’t ready for an overhaul of the health care system.

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Going Green In Health Care…

By CHARLIE BAKERI’m pretty sure that most public policy types believe they are doing
the right kinds of things to encourage a greener and more resource
sustainable economy.  And in many cases, I’m sure that translates into
a set of initiatives, laws and regulations that put the arm on private
sector organizations to do “better.”  I was thinking about this
yesterday as I was looking at the massive, paper, perfect
bound provider directories Harvard Pilgrim is required by MA state law
to produce.

I then started to think about all the paper we are required to
produce under various state and federal statutes and regulations, and
all the mailings and letters we are required to send out to various
constituents – providers, employers, members – under other state and
federal statutes.  I took a picture a couple of years ago of the amount
of paperwork – it covered a monstrous board room-like table in a very
large conference room – that the state of Massachusetts required us to
file to maintain our license to sell insurance in Massachusetts.  I
remember thinking then, “what a waste.”

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Be careful what you wish for

Charlie Baker is the president and CEO of Harvard Pilgrim Health
. This post first appeared on his blog, Lets Talk Health Care.

The show is
pretty much the same – every time. Public sector entity gets in budget
trouble, cuts have to be made, and providers who do business with the
public sector get hammered – hard. It’s happened with Medicare at
the federal level for years, and it happens with Medicaid at the state
level with some frequency as well.

Well, the show is back in town, as state governments face declining
revenues. In Massachusetts, the state is not only cutting Medicaid
payments prospectively – it’s cutting Medicaid payments for some
providers retrospectively – simply choosing not to make payments to
them they had planned on and expected.

I must say, each time this happens, I can’t help but wonder if the
hospital operators and physician leaders who think a single-payer like
Medicare For All is a good idea ever stop to think about how these
agencies deal with their financial problems.  When they have a problem,
they unilaterally whack their provider community hard – in ways private
sector payers would never consider.

And then those same providers who think Medicare For All is a great
idea turn to the private health plans they do business with and say,
“Hey – you need to help solve my Medicare/Medicaid deficit – which just
got worse.”

Sheesh. All I can say is, “be careful what you wish for.”

The never ending stent-bypass debate

A new study – a big one ($50 MM) – was recently released that compared the short and long term effects of drug eluding stents to bypass surgery for patients with serious heart disease.  The headlines — “Heart Surgery Bests Stents” — pretty much told the story.  In this particular case, 18% of those patients who had stents installed to treat their disease ended up either dying or needing another treatment over the next twelve months.  Only 12% of bypass patients ended up with complications or passing on.  The death rate in both instances was the same – 8%.

Stents — the tool of choice for interventional cardiologists — and bypass surgery — the technique of choice for cardiothoracic surgeons — have been playing this “which is better” game for almost ten years. Needless to say, both sides were represented in the stories that ran covering the results of this study. The bypass surgeons said, “More people should have bypass surgery instead of stents.” The stent docs said this study proved that stenting – which involves a much less aggressive and invasive procedure than bypass surgery — comes in a close second to bypass surgery, even in patients with complex conditions.

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Inappropriate ER use across the board

Charlie Baker is the president and CEO of Harvard Pilgrim Health
. This post first appeared on his blog, Lets Talk Health Care.

A few months ago, the New England Healthcare Institute (NEHI) issued a report on non-urgent use of Emergency Departments. It didn’t get that much public attention, which is too bad. It offered some interesting insights.

First of all, inappropriate — or non-urgent — use of the Emergency Room was not limited to uninsured populations. It showed up across the board. People covered by private insurance, Medicaid and Medicare were just as likely to use the ER for non-urgent care as people without health insurance. About 20 percent of all ER visits by privately insured and Medicare patients were for non-urgent purposes. About 24 percent of all ER visits by Medicaid beneficiaries and people without any insurance were for non-urgent purposes.

Second, another 25 percent of all ER visits for each group were for primary care treatable/preventable maladies. In other words, almost half of all ER visits were either for conditions that could have waited at least 24 hours to be addressed, or could have been solved in a doctor’s office.

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The affordability factor must accompany discussions on health care coverage

Charlie Baker is the president and CEO of Harvard Pilgrim Health
Care, Inc., a nonprofit health plan that covers more than 1 million New
Englanders. Baker blogs regularly at Let’s Talk Health Care.

I was in a meeting the other day when someone said — mostly in exasperation — "Everyone’s for affordable health care for everyone, but no one cares very much about dealing with the cost of health care.”

I’m sure that truer words have been spoken, but I can’t think of any off the top of my head. It’s too bad. Somehow, we’ve divorced the coverage/affordability question from the cost question, and we pay for it – everyday. 

In a recent article in the Journal of the American Medical Association (JAMA), bio-ethicist Zeke Emanuel from the National Institutes of Health, put it pretty well — “Without controlling health care cost, any attempt at universal coverage will be transient. Sustainable expansion of coverage to all Americans requires credible changes in the rate of health care inflation. In the strange calculus that is American politics, the more politically salient issue of costs may provide a better way to achieve the comprehensive reforms necessary to cover the uninsured that the hitherto futile direct moral appeal.”

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