Last week, the Massachusetts House of Representatives released a bill proposing big changes to how we pay for health care. While it consolidates a few state agencies, the House bill creates a massive new agency, the Division of Health Care Cost and Quality. The Division is given broad regulatory powers that can reach into most aspects of health care. Since the Division’s management will decide where billions of dollars will be directed and how millions of lives are treated, do we trust their judgment?
Strikingly, the Division will be independent and “not subject to the supervision and control of any other” public entity. Given that health care contributes to 18 percent of our state’s economy, are we comfortable with bureaucrats having so much power? Do we think they will have the expertise, resources, or shared values that we do to balance the tradeoffs associated with government-centered cost controls?
The controversial federal Affordable Care Act (ACA) was pilloried for granting the Secretary of Health and Human Services liberal authority to act on major policy roughly 700 times in 2,700 pages. This new Massachusetts bill outdoes the ACA, instructing the Division to act on policy almost every page — 163 times in 178 pages. The bill mandates action 941 times, using the legal term “shall.”
The new Division is given a dizzying array of responsibilities. It will assess a number of penalties, fines, and surcharges on hospitals, insurers, and others. There are 26 such fees in the bill. Some fees are levied once, others are reoccurring and some are sticks to be utilized by government to guarantee compliance to state mandates. You can bet the costs will be passed onto patients.
The Division will set “acceptable” standards for new methods to pay for health care called alternative payment methodologies. It will develop quality metrics for our care but limits insurers’ use of extra or better quality data outside of these approved metrics.
The Division will define and oversee how our medical care is coordinated in newly mandated accountable care organizations (ACO), networks of medical providers that, in theory, will help better organize your care. (By the way, research on the effectiveness of ACOs and alternative payment methodologies to save money is mixed.)
But we are moving ahead with both anyway.
The Division will design and manage the statewide health technology infrastructure needed to meet the mandated statewide 5-year window for all providers to be using health IT contained in the bill. It will implement extensive mandated transparency mechanisms for consumer education on cost and quality data.
Of course, you cannot legislate reality. And the reality is as that transparency without the right incentives for consumers leads nowhere.
For many patients, high-cost still correlates with higher quality in medicine. A recent report from Attorney General Coakley proved this theory wrong. But simply providing patients with cost data without incentives in their health plan to choose the low-cost high-quality provider, will mean that many will select the most expensive care.
The Division’s mandate to establish uniform reporting, by statute must align with federal standards. Will the Division follow the federal ACA’s lead establishing 140,000 coding categories? (Will patients bitten a second time by a turtle use billing code W5921XD?)
Will the Division have the expertise and technological knowledge to implement the many goals laid out in the bill? Consider the last state health care reform in 2006 and its health Care Cost and Quality Council. It boasted a great advisory board but struggled to produce a meaningful web product with wide market penetration.
Lawmakers should ask if it is a good investment to ask a public entity to run so much, especially since many of the new Division functions will be replicating activities already done in the private and non-profit sectors. What will the Division cost to run? The smaller Connector created in 2006 costs roughly $30 million a year to operate. How much more should we expect this mega-agency to cost?
And then there is the privacy of health information. The bill currently waves its hand at this complex and expensive issue, and serious thought is required.
The House bill’s language is rife with punts on the hard issues. The Division is instructed broadly to “take actions necessary to ensure….” or “promulgate regulations or guidelines to implement the findings of this section.” The Division’s management will be instrumental in shaping the future health care you receive in the Commonwealth.
Do we trust their judgment?
Also seen in Wicked Local Wrentham, Holliston TAB, Milford Daily News, Wicked Local Norfolk and Ipwich Chronicle