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Connector Update

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By PAUL LEVY

This report of recent activity in Massachusetts may be of special interest to my out-of-state readers. The insurance exchange set up by the Legislature when the MA health care access bill was passed has gotten very good grades. The folks there have had many things to balance, and they have done it thoughtfully. This report was posted on April 22 by Glen Shor, the current Executive Director. He succeeded Jon Kingsdale last April.

April showered us with reasons to be optimistic about the state of health care reform in Massachusetts.

Faced with projected 11% membership growth in the Commonwealth Care program next year as people lose unemployment benefits – and no additional resources to cover that growth – we encouraged our Medicaid managed care organizations to deliver high-quality, cost-effective coverage for less. They came through for the taxpayers with savings of $80 million, meaning that our members will not have to face the prospect of benefit reductions or unaffordable co-payments.

There was also good news for small business owners looking for an easy way to find affordable health insurance for their employees. Starting in July, we are eliminating all up-front fees for purchasing coverage through the Health Connector and will be launching a wellness program and premium discounts for qualifying small businesses. Within a few months, we will also be expanding the choice of health insurance carriers available to small businesses through our easy-to-use, online shopping experience – and even adding an additional carrier for individual purchasers. Our unsubsidized Commonwealth Choice program has doubled in membership over the past year-and-a-half, and these upgrades should make it an even more appealing tool for comparing options and choosing coverage that best suits one’s needs.

And, of course, the fifth anniversary of Massachusetts health care reform was officially marked by Governor Patrick and others at the Dorchester House this month. While we are proud of the fact that 98.1 percent of our residents and 99.8 percent of our children have coverage, the event poignantly showcased that reform isn’t just about numbers. It’s about helping people. We’re succeeding on both fronts.

On the national scene, the Massachusetts experience continues to be closely examined as other states begin to develop their health insurance Exchanges. Partnering with MassHealth and the University of Massachusetts Medical School, we were successful in obtaining a $35.6 million three-year federal grant that will not only help us share our technological knowledge and practices with other New England states but also improve our web-based shopping experience for Massachusetts consumers and small businesses.

“Trust Us” Just Doesn’t Cut It

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By PAUL LEVY

I apologize in advance if some of you are tired of hearing about Massachusetts and its experience with different payment models for health insurance. I write about this, not only because it is interesting locally, but also because people around the US are watching to see how the experiments here might or might not be applicable to the rest of the country.

I have written before about the pro’s and con’s of capitated, or global, payments as an alternative to fee-for-service payments. There are arguments to be made in support of each. But the problem in this state is that the movement towards global payments has become a matter of religious dogma. The main practitioners of the system have not been willing to divulge the kind of information needed to evaluate it properly. That lack of transparency undermines the policy arguments that might be used to advocate for an expansion of this approach.

But, eventually, more and more of the story comes out, and it is less than pretty. A few weeks ago, I quoted a report by the state’s Inspector General in which he raises concerns about this issue. He noted, “[M]oving to an ACO global payment system, if not done properly, also has the potential to inflate health care costs dramatically.”

Now comes an article by Pippin Ross in Commonwealth Magazine, entitled “Piloting Global Payments.” It has some revelations that give credence to the concerns raised by the IG.

Ross quotes a Blue Cross Blue Shield official as saying:

Blue Cross padded first-year global payment budgets to entice hospitals and doctors to sign on…. [T]he current goal is not to actually reduce costs, but to cut in half the rate of growth in medical costs after five years.

[T]he outcomes after one year under global payment are where Blue Cross expected to be in three or four years. “The amount of money being spent hasn’t changed yet, but the outcomes are serious testimony to the fact that more—in tests and doctors and visits—isn’t always better,” she says. “We’re getting a lot more for our money than we expected.”

But, of course, we don’t really know, do we? We have no way to validate any of this. Sorry, but “trust us” just doesn’t cut it when it comes to this kind of significant change.Continue reading…

The Massachusetts Mistake

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By ROGER COLLIER

A year after the passage of health care reform, fewer than half of Americans support it, a similar percentage believe that it has already been found unconstitutional or soon will be, health care costs are continuing to rise far faster than the CPI, and the Republican Party has seized on the issue as a sure election winner.

The Obama administration and congressional Democrats, now thoroughly on the defensive, are clearly surprised at the public and political reaction. But should they be? This post—on the reliance on Massachusetts as a model—is the first of three that will look at some of the miscalculations—and sheer bad luck—that have helped to undermine reform. When Governor Mitt Romney signed Massachusetts’ reform bill into law in 2006, it was widely regarded as a bipartisan political triumph, and one that was supported by the public and by most of the state’s insurers and providers. Massachusetts would be the first state to require virtually all legal residents to have coverage (with tax penalties imposed on those not complying), while providing subsidies for lower-income individuals not eligible for government programs, as well as to implement a state-administered brokerage function (the Connector) to allow competitive selection of health plans. By the fall of 2008, as congressional efforts to design national health care reform moved into overdrive with the election of Barack Obama, the Massachusetts legislation was widely regarded as a success. Public reactions were generally positive, the numbers of uninsured had fallen, and there had been no dramatic increase in costs. It was scarcely surprising that the Massachusetts model emerged from the field of competing proposals as the favorite of most Democratic lawmakers.

Unfortunately, the elected officials in Washington DC failed to recognize that Massachusetts was an exceptional state in terms of health care. Even before the state’s reform bill was enacted, the percentage of uninsured was very low. It was also a socially very liberal state, far more likely than most to support reform efforts (in fact, Massachusetts had passed, but then revoked, a slightly different version of health care reform a dozen years earlier). And, of course, the economy was still in its boom period when the new law was passed. Massachusetts had other advantages that would not transfer to national reform. As a small state, with only a small percentage of the population likely to be directly affected by reform, implementation could be much faster—less than a year for most provisions of the state’s new law. Continue reading…

The Inspector General Observes

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By PAUL LEVY

A recent report by the Massachusetts Inspector General raises a thoughtful concern about the implementation of global payments in the state.

In the effort to contain health care costs, much discourse has centered on moving from a predominantly fee-for-service system to one based mainly on global payments to providers organized as Accountable Care Organizations (“ACO”). There is little doubt that fee-for-service reimbursements create incentives for providers to increase utilization of health care services, with obvious inflationary consequences. But moving to an ACO global payment system, if not done properly, also has the potential to inflate health care costs dramatically.

There is nothing inherent in the current marketplace that would cause an ACO-based global payment system to contain health care costs. The evidence, in fact, suggests the opposite conclusion. For the past two years, the primary experiment with global payments in the private insurance market in Massachusetts has been the Alternative Quality Contract (“AQC”) popularized by Blue Cross Blue Shield of Massachusetts (“Blue Cross”). The payments to providers under this contract are made on a global capitated basis. The capitated amounts are determined by starting with the previous year’s experience of the population of lives covered by the specific AQC. That entire amount becomes the base year from which all future payments are derived. Therefore, the AQC embraces and adopts any excessive or wasteful payments in that base year, including all overutilization resulting from over a decade’s worth of fee-for-service provider contracts. Implicitly, the premium increases of that decade, which overall were well in excess of 100%, are made a permanent part of our health care system’s cost structure.Continue reading…

AQC to ACO: As Goes Massachusetts, So Goes the Nation?

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By DAVID HARLOW

About four years ago here in Beantown, survivors of the last big ill-conceived or poorly-executed (depends who you ask) wave of health care management and finance innovation were kicking around for a new approach to aligning payor and provider incentives, focusing on quality and cost containment. To hear Andrew Dreyfus, CEO of Blue Cross Blue Shield of Massachusetts, tell the story, the Blues wanted to address both quality and cost, and therefore (after looking in vain for a model elsewhere that could be transplanted to Massachusetts) developed the Alternative Quality Contract, or AQC, which features a global payment model hybridized with substantial performance incentives, plus design features intended to lower the cost of care over time.

Many of the features put in place under the AQC will allow participating provider networks in Massachsuetts to make the leap to ACO (once the beast is defined by the federales), despite the difference in payment methodology (global cap for AQC vs. FFS for ACO).

I was invited to hear Andrew present the AQC story this week together with Gene Lindsey, CEO of Atrius Health, a Massachusetts multispecialty physician network of some 700 physicians that participates in the AQC.  (Atrius’  largest group is Harvard Vanguard Medical Associates, whose docs used to be employed by Harvard Community Health Plan, the pioneering staff model HMO ’round these parts.)Continue reading…

Massachusetts has the best health care in America?

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By PAUL LEVYPaul Levy

A well regarded local hospital administrator last week said, “There is lots of evidence that Massachusetts health care is the best in the country.”

The context was a discussion in which it was pointed out that health care costs in Massachusetts are above the national average, even adjusted for wage differences. The statement was made to suggest that it is worth paying a bit more if what we actually get is better.

I was taken aback. I have never seen any evidence to support this conclusion. Would anyone care to offer quantitative support for the proposition — or against it?

Paul Levy is the President and CEO of Beth Israel Deconess Medical Center in Boston. Paul recently became the focus of much media attention when he decided to publish infection rates at his hospital, despite the fact that under Massachusetts law he is not yet required to do so. For the past three years he has blogged about his experiences in an online journal, Running a Hospital, one of the few blogs we know of maintained by a senior hospital executive.

The Massachusetts Connector: Success or Just a PR Coup?

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By ROGER COLLIER Roger Collier

With the passage of insurance exchange legislation in California, and the release of a template for state exchange statutes by the National Association of Insurance Commissioners, many state eyes are turning towards the only existing exchange comparable to that required by PPACA: Massachusetts’ Connector.

The Connector, which offers Commonwealth Care subsidized coverage for those with incomes below 300 percent of FPL but not eligible for Medicaid, and Commonwealth Choice private plans for other families and individuals and small employer groups, has been touted as a major success by current and former Commonwealth officials and many national reform advocates.

But, after four years of operation, just how successful has the Connector really been? Has it simplified health plan choice and enrollment, increased the number of insured, reduced marketing costs, created competition, or driven down premiums? It turns out that the answers are far less positive than the Connector’s boosters have admitted.

HAS THE CONNECTOR SIMPLIFIED PLAN SELECTION AND ENROLLMENT?

For some, at least.

For the 33,000-enrollee unsubsidized CommChoice program the answer is yes. Health plan selection and enrollment for the seven plans (with six levels of benefits each) is directly available via the Connector website, with simple well-designed screens and navigation, and easy comparison of alternatives. Even so, only half of thepost-reform non-subsidized insured have chosen coverage via CommChoice.

Continue reading…

Massachusetts Update

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By PAUL LEVY
Paul Levy 1Here is one of my occasional updates on theMassachusetts scene, for people looking for hints as to the kind of issues that might arise nationally as health care reform is implemented.

I have written several times about the ongoing saga between the state administration and the health care insurers in the state concerning premiums for small businesses and individuals. Over the last several weeks, several insurers have reached settlements with the Division of Insurance. At least one has not and has prevailed at the appeals board because the rates forced upon it by the state were not actuarially sound. Where settlements have been was reached, they were not based on actuarial principles: They was based on a desire to get past this impasse and provide some stability to customers.Continue reading…

Contradictions in Massachusetts

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By PAUL LEVY
Paul Levy 1

I have written before
about the strange things going on in the Massachusetts health care
insurance market. For those from out of state, here are some quotes
that will give you a sense of the contradictions in the public policy
arena.

They are, respectively, from two stories that appeared on
the same day in the Boston Globe:
"Rate
cap for insurer overturned" and "Officials
give up cutting health perks."

(1) An insurance appeals board yesterday overturned the state’s
cap on health premium increases for small business and individual
customers covered by Harvard Pilgrim Health Care . . . [finding] that
rate increases Harvard Pilgrim initially sought in April are
reasonable given what it must pay to hospitals and doctors. That ruling
trumped the Insurance Division’s earlier finding that the requested
increases were excessive.

(2)
The state’s public employee unions won a major victory this week when
the Legislature abandoned efforts to allow cities and towns to trim
generous health care benefits enjoyed by thousands of municipal
employees, retirees, and elected officials.

You can read
the rest and related stories, but what is most disturbing is that the
spirit of cooperation and compromise that existed when Massachusetts
approved its health
care reform law in 2006 has broken down. Part of the reason is
that commitments made at that time have not been delivered upon. For
example, the state had promised to lift Medicaid payment rates to
something closer to the cost of delivering that service. Once the
economy sank and state budgets were stressed, that was not possible.
This left providers needing to collect more of their income from private
insurers.

Continue reading…

Dislodging the anchor

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By PAUL LEVY
Paul Levy

A well-established technique in negotiation is to “set an anchor.” The
idea is to be the first person to put out an offer in a negotiation in
which price is the main issue. Many people think, incorrectly, that you
are better off if you let the other party make the first offer. But,
no. An anchor, once set, has a powerful impact on the negotiation,
causing the final price to settle in its vicinity — even if the anchor
has no substantive basis.

I fear that we are seeing this phenomenon happening in Massachusetts. Many of you have followed our
current controversy regarding insurance rates for individuals and small
businesses. Lots of people with these kind of insurance policies found
themselves with large premium increases this year.

Continue reading…

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