Discussing the Cost of Care at the Health Policy Commission
Beginning in 2006 with the passage of Chapter 58 to create universal access, affectionately known as Romneycare, and extending through 2012 with the passage of Chapter 224 meant to bring the cost of care under control, the Massachusetts legislature has passed a series of laws that have represented a legislative effort to force the transformation of care toward the ideals of the Triple Aim. There was a new law almost every year. I have often said that the medical community of Massachusetts was not listening to the concerns of voters, activists or employers in the state, so a coalition evolved that got the legislature to be their megaphone.
Perhaps the most remarkable pieces of Chapter 224 were the establishment of the concept that the total cost of care should not increase more in one year than the growth in the state’s GDP, the establishment of the Health Policy Commission to supervise the further evolution of the management of the cost and quality issues, and the creation of an annual Cost Trends report after which the HPC would hold hearings on the findings. The law also created CHIA, the Center for Health Information and Analysis and gave it the power to collect and analyze the data that would support the work of the HPC.
The HPC has members who are on the Governor’s cabinet as well as experts from academia and the community. By law no commissioner can be an active clinician, or an employee or board member of a firm doing healthcare business in the state, including hospitals and insurers. To counter this exclusion of the voice of the industry, an Advisory Council was created that explicitly included stakeholders in healthcare and representatives of the community. The Council was constituted to meet regularly to review the work of the HPC and provide advice. All meetings of the HPC and the Advisory Council are open to the public. One goal of the whole process is transparency. The website of the HPC describes the role of the commission as:
The Massachusetts Health Policy Commission (HPC) is an independent state agency that develops policy to reduce health care cost growth and improve the quality of patient care. Among other initiatives, the HPC is responsible for monitoring the performance of the health care system, analyzing the impact of health care market transactions on cost, quality, and access, setting the health care cost growth benchmark, and investing in community health care delivery. The HPC’s Board governs the activities of the agency.
The HPC's mission is to advance a more transparent, accountable, and innovative health care system through its independent policy leadership and investment programs. Our goal is better health and better care at a lower cost across the Commonwealth.
The major flaw in the design of the the legislature was that the HPC was not given any power to enforce its findings or opinions. As a result the HPC can render opinions, as it did on the Partners’ proposed expansion, but it falls to other official agencies or state officers to enforce the policies. The goal of keeping the increase in premiums or the total cost of care under the growth rate of the economy can be violated without penalty. Despite the limitations of its powers, I have great respect for its members and Stuart Altman, its venerable Chairman. I am very encouraged by the fact that the newest member of the HPC is Don Berwick.
As I reported in previous letters and on the SHC website, the Cost Trends Hearings for 2014 revealed the concern that the trends were exceeding expectations and recent filings for approval of rate hikes for 2016 by the insurers suggest that costs are out of control and some insurance rates are increasing at multiples of the GDP. These were the hard realities that were the focus of discussion at the Advisory Council. It was gratifying to hear that many of those sitting around the table rejected the idea introduced by the Governor and others at the Cost Trends Hearings that if you factored in the median income in Massachusetts to the analysis there was no real problem with healthcare costs.
There were some pieces of good news. Interest is high as reflected by the fact that over 4000 people listened to the two day Internet broadcast of the Cost Trend Hearings. Other good news was the fact that we are in the comment period of regulations that will define and control the work of ACOs in Massachusetts. The state has decided to enhance the certification of PCMHs by accepting the NCQA criteria and then adding to those descriptors several criteria to support the integration of Primary Care with Behavioral Health. The new category will be called PCMH Prime. Much of the discussion at the Advisory Council underlined the impossibility of lowering the cost of care without integrating Behavioral Health with Primary Care.
It was my opinion that there was an initial tendency to blame the ongoing failure to control costs on the confusion of who should be covered in the expansion of Medicaid and the rapidly increasing cost of medications. There was a substantial push back against these explanations by many members of the Council, myself included. The final statement of the meeting was made by former State Representative Stephen Walsh who is now the The Executive Director of the Massachusetts Council of Community Hospitals. Mr. Walsh was one of the primary authors of Chapter 224 when he was the Chairman of the House Committee on Health Care Financing where he oversaw the drafting and passage of Chapter 224. His closing remark was that to control the cost of care we needed to rapidly move away from fee for service payment toward alternative payment mechanisms and ACOs.
I know that my friend Dr. Patty Gabow worries about the future of Medicaid. Blaming the failure to control costs on Medicaid is not productive. The loss of the improvement in access that could have been achieved with the full expansion of Medicaid that was a part of the ACA but reversed by the Supreme Court remains an ongoing injustice and inequity for the residents of many states. It is alarming that even in a state like Massachusetts, where Medicaid has been a part of the access to care for a long time, Medicaid remains vulnerable to the blame for the cost crisis in healthcare.
What does all of this mean? To me it says that there is reason to be hopeful that the Medicaid expansion conceptualized as an important part of the ACA will eventually be accepted by every state. It also suggests to me that we should seriously reflect on what Martin Luther King, Jr. said about the injustice of healthcare discrepancies. Is it right for the working poor in one state to have access to great care and persons with exactly the same economic status not have access to care because of their state of residence? It is a situation that we seem to accept without much discussion.
Good Bye to a Giant
Before going to Boston for the HPC Advisory meeting, I had emailed my friend Chris Jedrey who is one of our leading healthcare attorneys, to ask him if he was free for a walk on Wednesday afternoon since his office was near the site of my meeting. I took the picture in today’s header as we walked across the Boston Public Garden. Chris and I enjoy getting together as often as possible to get some exercise while we talk about a whole list of things from history and literature to healthcare. At the time Chris accepted my invitation for the walk, we did not know that our mutual friend and colleague, Dr. Lawrence Cohn would pass away before we walked.
On Monday morning I was very surprised when my wife looked up from the Globe Obits and expressed shock and sadness as she read the brief obituary of one of the true giants of cardiac surgery in Boston and in the country. She caught me completely off guard when she exclaimed, “Larry Cohn has died!” She had worked with him for many years as a cardiothoracic clinical nurse.. The initial death notice was just a few sentences long. The notice did provide functional information about receiving hours and where to send donations in lieu of flowers. I was relieved when on Tuesday there was an appropriate Globe article that outlined his remarkable career.
After the initial shock it was hard not to think about Larry. I can still remember the introduction he received at Medical Ground Rounds at the Brigham when he was introduced shortly after coming to Boston from Shumway’s program at Stanford where he had been a star. It was 1972 and I was a lowly junior resident in medicine but did have several points of contact with him over the next few years as a resident and then a fellow in cardiology. It did not take me long to observe that his patients did extremely well. I also was surprised that he had an openness that made him one of the most approachable senior physicians or surgeons in that great institution.
A few years later I had become the cardiologist at Harvard Community Health Plan and made the decision, based on my experience working with many different and excellent surgeons, that I would preferentially refer all of the elective cardiac surgical cases to Larry. My reason was that I felt that it would be beneficial to have a close relationship with a specific surgeon and Larry got the best results. Over a period of thirty five years my colleagues and I referred hundreds, perhaps more than a thousand patients to Larry for cardiac surgery. Many of our patients were quite complicated valve cases, or patients with coronary disease with reduced left ventricular function. There were a few patients with subaortic stenosis. Many were patients who other surgeons would not touch and were left with little hope of gaining any significant improvement in their functional status. Everyone of the hundreds of patients that Larry and I shared survived the OR.
There were only two patients who died. In 1977 there was a dear man in his fifties with rheumatic heart disease and a very large ventricle and severe CHF from mitral regurg who begged for a chance to have his life improved. After much consideration Larry offered him a chance but he had a difficult post op course and eventually died. I am convinced that with the advances in management over the next ten years he would have survived and have been greatly improved. The other postoperative patient death occurred in the mid nineteen eighties and was in an older man who was a “redo” CABG. He developed bleeding complications a week or so into a difficult recovery. That’s it! Every other case went well. His results were hugely better than all of the other very fine cardiac surgeons. His survival rates were better than the fielding percentage of a gold glove major league shortstop!
After walking about four miles Chris and I retired to the Starbuck’s at the corner of Beacon Street and Charles. The subject by then was our sense of loss with Larry’s passing. It was a great pleasure to sit with Chris and share memories of our individual encounters with Larry over the years. We agreed that Larry’s success and his ability to help patients were a function of a few important factors. First, he was committed to excellence. In the OR he had very “fast hands”. He also did only what was necessary. He responded quickly and efficiently to surprises when they occurred. He knew the patients well and he made very careful plans that he was willing to adjust when problems developed. He seemed never to do anything that did not add value. Larry took great pride in the quality of what he could do.
From my point of view he was a terrific colleague who would always take my call. I did not realize until Chris and I began to reminisce on our walk that Larry also took surgical referrals from lawyers. For both my patients and patients that Chris referred to him, he would manipulate his schedule to see any patient who needed to see him soon. He always called me immediately after the surgery was completed to give me the information that I needed when I talked talk with the family. Now I know that he also would call Chris to let keep him up to date. Many surgeons will say that they tried to call you. Larry kept calling until he got through to you.
Larry always treated me with respect and always listened to me as I tried to give him my understanding of our mutual patient as a person. As we were exchanging stories I told Chris that Larry even went out of his way to break protocols that added unnecessarily to the cost of care. Most remarkably, he once sat with me to help figure out the least expensive way to do a CABG on the sister of one of my patients. She was coming from Eastern Europe. She was paying out of pocket. Through a variety of maneuvers which probably included no fee for him, we cut the cost by more than fifty percent.
Chris and I shared many more Larry Cohn stories. Suddenly we realized that it was dark. Chris’s office had called him more than an hour earlier about a meeting that he had now missed. We were having such a good time remembering a great doctor that we had lost track of time. Thoughts of Larry had left us smiling and filled with gratitude for what he had meant to our patients, our friends and our community. Larry’s impact was international. He was one of a kind. He was a master surgeon who loved his craft and loved improving the lives of others. Despite his international fame, he was never distant and never too busy to collaborate in the pursuit of better care.
Bad Weather and Kansas City are Blowing in for the Weekend
I must admit that I am worried. Many of the Patriots are in various states of recovery from significant injuries. Our offensive line in particular is thin. TB12 is great but no quarterback functions well without healthy blockers and receivers. The coach is inscrutable. Is he worried or is he depressed? Why did he throw away that game in Miami? My granddaughter was there to root for the Gronk and the Patriots did not show up as they threw away the home field advantage. Now they may end up playing Peyton Manning and the Broncos in Denver where the air is thin and there are no comforts of home.
I will reflect on these and other things as I take my pre game walk in the snow that we are expecting tomorrow. I will also be thinking about Dr. King and his wisdom and humanity. We are very fortunate that he was with us, if only for a short time.
Stay in touch and have a very nice long weekend. I hope that you have time to listen to the “I Have A Dream” speech.
