Controlling Health Care Spending — The Massachusetts Experiment

Composition of Massachusetts Residents Newly Covered under Chapter 58 (as of 1/1/08) (Photo credit: Wikipedia)

As debate rages on about implementation of the Affordable Care Act (ACA), national attention is once again focused on Massachusetts, which instituted a similar comprehensive health care reform package in 2006. After expanding health insurance coverage to almost 98% of the state population, Massachusetts is now struggling to control increasing health care costs that threaten the continued viability of its reforms. This second phase of health care reform presents entirely new challenges. Whereas expanding coverage has popular appeal, cost control does not. Whereas expanding coverage injects additional dollars into the health care system, cost control does the opposite. Whereas expanding coverage can be relatively simple, cost control is difficult. Yet despite these obstacles, Massachusetts forges ahead, with a combination of public and private efforts at payment reform on an unprecedented scale.

Massachusetts spent more than $61 billion on health care in 2009, a figure that places it among the highest-spending states in the country.1 In the past 5 years, growth in health care spending has consistently exceeded economic growth, resulting in challenges both for lawmakers dealing with a constrained state budget and individuals required to purchase coverage privately. In fiscal year 2012, health care will consume 54% of the state's budget, up from 49% in fiscal year 2009, with the bulk going toward Mass Health (Medicaid) and individual subsidies for purchasing health insurance. For individuals, monthly premiums for a minimal (“bronze”) plan purchased through the Commonwealth Choice connector (the state insurance exchange) increased from about $175 in 2007 to $275 in 2012 (a 57% increase), despite slowed growth in overall health care spending since the start of the recession in 2008.

To address these concerns, Governor Deval Patrick convened the Massachusetts Special Commission on the Health Care Payment System, which voted unanimously in July 2009 to recommend that the state transition from a fee-for-service to a global payment system within 5 years. The commission also encouraged providers to band together into accountable care organizations (ACOs) — organizations of providers held jointly accountable for spending and quality of care for a defined population of patients. Meanwhile, the Health Care Quality and Cost Council, created by the 2006 coverage-expansion law, issued its Roadmap to Cost Containment in 2009; in it the council argued strongly for global payment and systemwide redesign to lower spending.2Recognizing that price and volume together account for spending, the Office of the Attorney General and the Division of Health Care Finance and Policy embarked on a landmark effort to document the substantial price variations in the state — illustrating, in several influential reports, the role of providers' market power in determining the prices charged to commercial insurers.3

These activities culminated in a comprehensive payment and delivery reform bill released by Governor Patrick in February 2011. The bill proposes migrating into global payment arrangements most state employees and Medicaid enrollees, groups that together include about 25% of Massachusetts residents.4 It also encourages but does not require providers to form ACOs — with the state providing oversight of market power and price transparency — and includes provisions for malpractice reform favored by physicians. The bill also grants the commissioner of insurance the authority to strike down increases in insurance premiums that result from excessive increases in underlying provider-payment rates. The appropriateness of increases in provider-payment rates will depend on how they compare with growth in the Massachusetts gross state product (the state-level equivalent of the national gross domestic product) and the growth of total medical expenses in the providers' particular region. Combined with global payment, this authority to indirectly regulate providers' prices would be among the strongest policy tools available for cost control. Since the bill's release, state legislators have been drafting their own proposals, and both public and closed-door debates have intensified. The legislative outcome remains unclear.

While the state aggressively pursues its agenda, innovations in the private sector have arguably taken the lead. Most notably, Blue Cross Blue Shield of Massachusetts, the largest commercial insurer in Massachusetts, launched the Alternative Quality Contract (AQC) — based on global payment with shared savings and shared risk, as well as pay-for-performance incentives — with seven provider organizations in 2009. Since then, the AQC has been extended to cover more than a dozen provider organizations and more than 600,000 enrollees. Encouraged by provider organizations and the AQC, Harvard Pilgrim Health Care and Tufts Health Plan, the state's other major insurers, have also negotiated global payment contracts with their provider networks, which will probably push the number of enrollees in commercial insurance plans that have global payment arrangements to more than 1 million.

Finally, and perhaps most important, the Center for Medicare and Medicaid Innovation launched its Pioneer ACO program in January 2012 with 32 advanced provider organizations around the country. Among them are 5 large organizations in eastern Massachusetts (Atrius Health, Beth Israel Deaconess Physician Organization, Mount Auburn Cambridge Independent Practice Association, Partners Healthcare, and Steward Health Care System), which will together care for approximately 150,000 Medicare beneficiaries (roughly 75% of Medicare beneficiaries in the Boston area) under their Pioneer contracts. Additional provider organizations in the state will probably join the Medicare Shared Savings ACO Program later this year.

These synergistic efforts by public and private payers have resulted in a watershed moment in Massachusetts health care. By our estimates, if the Group Insurance Commission, which purchases insurance for state employees, and Medicaid follow Medicare and commercial payers into global payment, substantially more than half of residents of eastern Massachusetts would be cared for by providers working under risk-based contracts. Primary care physicians will have the opportunity and responsibility to steer resource utilization for their organizations, and providers in all specialties will have strong incentives to better coordinate care, improve quality, and intensify their focus on patient-centered care. Referral patterns and the movements of patients from one provider system to another will probably change considerably. Similarly, with strong incentives to reduce spending, provider organizations will probably take an active role in identifying and discouraging the use of low-value services. Opportunities will be ripe for designing incentives within organizations directed at individual physicians as well as teams of providers.5

Yet immense challenges loom. Because enrollees in preferred-provider organizations and most employees of self-insured firms remain largely outside of global payment arrangements, the fee-for-service system retains a substantial role. With global payment expected to constrain spending for a growing proportion of patients, undesirable spillover effects, such as cost shifting onto the fee-for-service population, may occur. At a macro level, Massachusetts relies heavily on specialty-driven tertiary care delivery systems not only for its health care but also for jobs and the education of thousands of physicians-in-training each year. Indeed, health care is an engine of the Massachusetts economy. A crucial question is whether lawmakers will gain the stakeholder support needed to embrace cost control and tackle the roots and drivers of Massachusetts health care spending, given that unintended consequences for the labor market and the broader economy may lie downstream.

No matter the outcome, this wholesale Massachusetts experiment should offer invaluable lessons for other state and federal cost-control efforts, particularly as the ACA is implemented. One lesson is already resoundingly clear: the growth of health care spending threatens the sustainability of every other public service, from education, to public health, to infrastructure, to defense. Indeed, health care spending is the most important determinant of our growing national debt. In a society of limited resources, the imperative for cost control now comes from outside health care. Payment reform may well be a reasonable beginning, but fundamental reform of the delivery system is needed if we are to truly succeed.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

This article (10.1056/NEJMp1201261) was published on April 11, 2012, at NEJM.org.

SOURCE INFORMATION

From the Department of Health Care Policy, Harvard Medical School (Z.S., B.E.L.); and the Division of General Medicine and Primary Care, Beth Israel Deaconess Medical Center (B.E.L.) — both in Boston; and the National Bureau of Economic Research, Cambridge, MA (Z.S.).

REFERENCES

1. 1
   Centers for Medicare and Medicaid Services. National health expenditure accounts (httphttp://s://www.cms.gov/NationalHealthExpendData).
2. 2
   Massachusetts Health Care Quality and Cost Council. Roadmap to cost containment. October 21, 2009 (http://www.mass.gov/hqcc).
3. 3
   Examination of health care cost trends and cost drivers: report for annual public hearing, June 22, 2011. Boston: Office of Attorney General Martha Coakley (http://www.mass.gov/ago/docs/healthcare/2011-hcctd.pdf).
4. 4
   An act improving the quality of health care and controlling costs by reforming health systems and payments. Boston: Commonwealth of Massachusetts, 2011 (http://www.mass.gov/governor/docs/legislation/paymentreformlegislation.pdf).
5. 5
   Landon BE. Keeping score under a global payment system. N Engl J Med 2012;366:393-395
   Full Text | Web of Science | Medline

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The State of Comparative Effectiveness Research and the Environment for Health Care Decision Making

NPC discusses the findings from its third annual survey that gauges the attitudes and expectations of comparative effectiveness research (CER) among key health care stakeholders. Speakers include NPC President Dan Leonard and Director of Health Services Research Kimberly Westrich. AcademyHealth President and CEO Dr. Lisa Simpson and Patient-Centered Outcomes Research Institute (PCORI) Executive Director Dr. Joe Selby join the discussion on a reactor panel.

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En epocas de ajustes......alguien entenderà esto ?

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The Savings Illusion — Why Clinical Quality Improvement Fails to Deliver Bottom-Line Results

Stephen S. Rauh, M.B.A., C.F.A., Eric B. Wadsworth, Ph.D., C.P.A., William B. Weeks, M.D., M.B.A., and James N. Weinstein, D.O.

December 14, 2011 (10.1056/NEJMp1111662)

Article

References

It has become a core belief in U.S. health care that improving clinical quality will reduce health care costs. It seems intuitive that reducing readmissions, shortening lengths of stay, and building efficiency into clinical processes will reduce resource utilization and thereby lower costs. Certainly, evidence suggests that there is no association between high quality and high costs.1 Yet true bottom-line savings from improved clinical quality rarely materialize, and costs continue to climb. Manufacturing and service companies around the world have demonstrated the cost benefits of improving product quality and production efficiency. So why haven't nearly two decades of work on improving health care quality had a measurable effect on health care costs?

The explanation lies in the cost structure of the typical health care setting. Its management and organization create a rigid cost structure that is relatively insensitive to small changes in patient volume, resource use, or the severity of patients' health conditions. This fixed-cost dilemma leaves most health care costs insensitive to changes in volume and utilization, so clinical quality improvements typically create additional capacity rather than bottom-line savings.2 An examination of the different cost layers highlights the distinction between variable costs, such as supplies and medications, where reduced use produces true savings, and fixed costs, such as facilities and ancillary services, where the costs persist despite reduced use.

To better understand the cost structure of health care delivery, it can be useful to consider how different costs behave depending on the degree to which they are sensitive to changes in resource utilization. The four cost layers we have identified are defined in the tableBehavior of the Various Cost Layers in the Health Care System..

Clinical improvements that reduce layer 1 costs, such as those of supplies and medications, will generally create bottom-line savings, since these are the only truly variable clinical costs in a hospital. To generate savings by reducing use of the resources that account for layer 2 costs, the need for the resource must be reduced enough to allow elimination of a payable unit. For instance, a single nursing unit might have to discharge multiple patients before any savings in hourly nursing labor costs could be captured by allowing an hourly employee to go home early. Reducing layer 3 resources — those for equipment, operating-room time, or physicians' salaries, for example — almost always produces additional capacity without bottom-line savings. If an intervention reduces operating-room time by 15 minutes, the costs of the equipment and salaried staff required to run the operating room do not change. Nonclinical layer 4 costs are primarily fixed in the short run, but reducing administrative labor costs by achieving administrative efficiency will produce true savings in future operating cycles.

Because of these cost behaviors, quality-improvement efforts that reduce lengths of stay or readmissions or increase radiology throughput do not create substantive bottom-line savings. They generally create capacity to treat additional patients. Similarly, efforts to expand the access of disadvantaged populations to primary care under the assumption that such access will be paid for through avoiding use of high-cost care sites — such as emergency departments — do not generate cost savings. The cost of staffing and equipping an emergency department does not change if there are small reductions in utilization. Indeed, improved access will increase health care costs if new physicians and staff are hired to serve new patients in primary care practices.

Although capacity creation does not generate bottom-line savings, it does create an opportunity to admit another patient and collect additional revenue. Because health care costs are relatively fixed and do not change much at the margin, the cost of admitting a new patient is remarkably low, making volume growth a highly profitable strategy. Volume growth also can give the appearance of reducing costs, since the cost per case decreases when the high fixed costs are spread over a larger number of patients, although total costs will probably continue to rise. Growing volume and increasing revenue, rather than creating true bottom-line savings, are typically at the core of the business case for high-quality care.3

Because of the rigid cost structures, incremental reductions in resource use are unlikely to generate cost savings for either a health care setting or the health care system. The most meaningful way to achieve savings is to focus on overall reductions in utilization rates for health care services and to eliminate the associated unnecessary capacity.

In a recent article, Kaplan and Porter argue that most health care costs are not fixed.4 Postulating that personnel costs can be adjusted and space reallocated on the basis of demand and patient mix, they suggest that cost behaviors are not responsible for the inability to generate cost savings, but “management inattention” is. Although we do not dispute this logic, its practical application is dependent on both procedure volume and the time horizon required for aligning resources with demand. High-volume procedures and treatments for which resource use can be standardized across the cycle of care and for which capacity can be readily adjusted to accommodate appropriate volume appear to be best suited to the aggressive cost management advocated by Kaplan and Porter. Presumably, lower-volume treatments and procedures would have to be consolidated regionally to be more amenable to effective cost management. Until that happens, the fixed-cost dilemma will remain an obstacle. Cost layering provides management with a framework for targeting changes that will generate the most immediate savings.

Whereas quality improvement is producing significant benefits for patients, quality initiatives will continue to produce disappointing bottom-line savings as long as the capacity created is used to support growth in patient volume. As the U.S. health care system begins shifting its focus from volume to value, hospitals will need to adapt their cost structures and capacity to accommodate lower per capita utilization rates as well as reductions in the per-episode intensity of care.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

This article (10.1056/NEJMp1111662) was published on December 14, 2011, at NEJM.org.

SOURCE INFORMATION

From the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, NH.

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Defining Essential Health Benefits — The View from the IOM Committee

Source: NEJM

When Congress enacted the Affordable Care Act (ACA), it mandated that a broad package of “essential health benefits” (EHBs) equivalent to that of a “typical employer plan” be offered by qualified health plans participating in newly created state-based insurance exchanges, as well as by new plans offered to individuals and small employers outside these exchanges. Congress directed the Department of Health and Human Services (DHHS) to flesh out the details. The DHHS, in turn, asked the Institute of Medicine (IOM) to recommend a process for defining and updating the EHB package — but notably, not to develop a specific list of benefits.

In a report released on October 7, the IOM recommended that the initial EHB package be equivalent in scope to what could be purchased by the average premium that a small business would pay on behalf of an employee (see Key Recommendations of the IOM Committee on Defining and Revising an Essential Health Benefits Package for Qualified Health Plans).1 If the DHHS endorsed a more expansive package, the IOM's Committee on Defining and Revising an Essential Health Benefits Package for Qualified Health Plans cautioned in its report, many currently uninsured individuals and small businesses would find it unaffordable, which would undermine the overriding goal of the reform law — to make coverage both meaningful and nearly universal. To underscore its strong emphasis on affordability without elimination of appropriate coverage, the report said EHBs “should become more fully evidence-based, specific, and value-promoting over time,” and if additional services are added, “the package should be offset by savings” from the elimination of outmoded or unnecessary services and the making of prioritized choices among services supported by public dollars.

Over time, under the ACA, an estimated 30 million uninsured individuals and employees of small businesses (fewer than 100 workers) with low-to-moderate incomes will become eligible for federally subsidized coverage through insurance exchanges or expansions of Medicaid programs. Most employees will remain insured through grandfathered or self-funded employer plans offered by large companies and some small ones, and these plans are exempt from the EHB mandate.

The ACA stipulates that health plans must offer, to individuals and small businesses who seek coverage through an insurance exchange or outside of one, packages that “at least” include 10 broad benefit categories: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health and substance abuse disorder services, including behavioral health treatment; prescription drugs; rehabilitative and habilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including oral and vision care. The ACA allows states to require health plans to offer benefits beyond the defined set of EHBs, but states must assume the incremental costs for subsidies of any additional mandated benefits.

To standardize benefits and establish a basis for calculating premium subsidies, the law creates four plan levels that are differentiated by their actuarial value — the percentage of covered expenses that a plan is expected to pay out, on average, as distinguished from what is paid out-of-pocket by the consumer. These levels are bronze (paying on average 60% of covered expenses), silver (70%), gold (80%), and platinum (90%). Individuals with incomes up to 400% of the federal poverty level (currently $88,200 for a family of four) will be eligible for tax credits scaled by income to help defray the cost of coverage. Individuals with incomes at or below 133% of the federal poverty level are eligible to enroll in Medicaid, which has little or no patient cost sharing.

The IOM report identifies key challenges that the DHHS will face as it strives to equate the ACA-defined EHBs with the typical small-business package. For one, the conductors of an ACA-mandated Labor Department survey of documents from 3200 employer-sponsored insurance plans found it difficult to describe with much precision the benefits of a “typical” employer package.2 In addition, some benefits mandated by the ACA — such as habilitative services, wellness programs, and pediatric oral and vision care — are generally not included in standard small-employer or even large-group insurance contracts. The report notes that for employers, establishing a budget creates one way to explicitly consider benefit-package tradeoffs when resources are limited.

The committee decided to peg its budgeting target to the estimated average premium for a “silver” package — the second-lowest-priced plan available through an exchange and the level to which the ACA's premium subsidies are linked. The report suggests that the DHHS's selection of benefits be guided by an estimate such as that prepared by the Congressional Budget Office (CBO)3 and converted to 2014 dollars by the IOM committee — $6,933 for an individual policy (see tableEstimated Health Insurance Premiums for Individual and Family Policies without the Affordable Care Act (ACA) and after Its Implementation.) — or a RAND estimate of $5,474 for a silver plan when individual and small-group risk pools are combined.4 To build on those estimates, the IOM recommended that the DHHS seek actuarial advice on the costs of all elements of the EHB plan, including benefit-design features such as the degree of medical management, provider payment rates, and patient cost sharing. Actual premiums for plans would vary, as they do now, with the geographic area, population enrolled, and other factors.

As part of its assigned task, the IOM committee was asked to evaluate definitions of “medical necessity review” that are found in private insurance contracts. The committee concluded that such processes and other medical management techniques (e.g., prior authorization) “with appropriate checks and balances, are necessary to ensure that the package of EHB benefits can be delivered at the most affordable cost.” The ACA requires the establishment of an independent external review of appealed medical necessity cases. The committee decided not to recommend a single national definition of medical necessity but added: “The criteria used for medically necessary services or services that conform to medical necessity are medical services that are (1) clinically appropriate for the individual patient, (2) based on the best scientific evidence, taking into account the available hierarchy of medical evidence, and (3) likely to produce incremental health benefits relative to the next best alternative that justify any added cost.” These criteria are consistent with best practices and supported by legal precedent.

The IOM report acknowledges that “the determination of the EHB is a politically and socially charged endeavor.” Recognizing the controversy the EHBs could provoke, the committee recommends that the DHHS create a “structured interactive process” to advise the department on reconciling “the tensions between comprehensiveness and affordability.” From its beginning, the panel agreed unanimously that if the long-standing problem of rising health care costs is not addressed more aggressively, the ACA's goals of reducing the uninsured population (49.9 million people, or 16.3% of the population, in 2010, according to the U.S. Census Bureau) and offering meaningful benefits could be undermined.

The report said the cost trend will not be moderated only by the definition of EHBs and added: “The committee considered whether complementary Medicare-only or federal-only approaches to reducing rising health costs would be sufficient and concluded they would not be. An all stakeholder strategy is required across the public and private sectors,” and the ACA-created independent payment advisory board, even if it survives strong opposition to its creation, will not include formal engagement of the private sector. By expressing its concern over health care costs whose annual increases outstrip the growth of the economy, the committee has issued a wake-up call for policymakers, clarifying how this spending pattern squeezes out other important competing needs, particularly in a no-growth economy. However, such previous warnings, as often as they have been issued, have largely fallen on deaf ears.

KEY RECOMMENDATIONS OF THE IOM COMMITTEE ON DEFINING AND REVISING AN ESSENTIAL HEALTH BENEFITS PACKAGE FOR QUALIFIED HEALTH PLANS.*

1. The secretary of health and human services should establish an essential health benefits (EHB) package including the 10 categories contained in the Affordable Care Act and as guided by a national average premium target. Once developed, the package should be adjusted so that the expected national average premium for a “silver” (second-lowest-price) plan is actuarially equivalent to the average premium small employers would have paid in 2014 for a typical plan. A public deliberative process should be used to make adjustments to the initial EHB package.

2. By January 2013, the secretary should establish a framework for monitoring EHB implementation and updating that accounts for changes in provider payment rates, financial incentives, practice organizations, and other relevant matters. The secretary should implement this framework and coordinate federal efforts to produce and make the data accessible for public use.

3. Beginning in 2015, the secretary should update the EHB package to make it more fully evidence-based, specific, and value-promoting — explicitly incorporating costs. A public deliberative process should be used to inform choices about what to include in or exclude from the updated package.

4. The secretary should permit states administering their own exchanges to adopt variants of the federal EHB package, provided that modifications are consistent with the federal package, not significantly more or less generous, and are subject to public input.

5. The secretary should establish a National Benefits Advisory Council, with members appointed through a nonpartisan process, which should make recommendations annually stemming from its oversight of the EHB package.

6. To ensure that the EHB-defined packages remain affordable and sustainable, the secretary should develop a strategy, in collaboration with others, for aligning the growth rate of health care spending in all sectors with that of the economy.

* Summarized from the Institute of Medicine Committee report.1

Disclosure forms provided by the author are available with the full text of this article at NEJM.org.

This article (10.1056/NEJMp1109982) was published on October 7, 2011, at NEJM.org.

SOURCE INFORMATION

Mr. Iglehart is a national correspondent for the Journal.

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