Summary of health care outcomes: does Massachusetts lead the nation?

The recent assessment of the Massachusetts health care reform, released April 12 by the Blue Cross Blue Shield of Massachusetts Foundation is a quick read and well worth perusing by people outside the state. Because Massachusetts anticipated much of the US health care reform effort, this report gives us a glimpse of what can happen in the country as a whole when the provisions of the federal law fully take effect.

There’s lots of good news: nearly everyone in the state has some insurance now, fewer people report “significant out-of-pocket health expenses,” and the bill is popular. It is supported by nearly all physicians, most employers, and two-thirds of state residents as a whole.

The downside, of course, is the cost. More people have trouble paying for care, which seems to clash with the statistic on lower out-of-pocket expenses. The culprit is probably the rise in premiums and the backing off of employers, who are paying for less of the cost of their plans. And I refuse to blame rising costs on the health care bill; it’s a worldwide phenomenon.

Everybody in the state knows very well that costs have to be attacked. The governor drew a line in the sand by denying requests for high premium increases from the insurance companies. Blue Cross Blue Shield itself is trying a new system similar to the Accountable Care Organization model being widely touted. I am a member of Greater Boston Interfaith Organization, which is planning a campaign around costs as its next phase of political action.

It was a relief to read about some negative predictions that didn’t happen. Employers for the most part did not abandon their own health plans and throw their workers into state plans. Most uninsured did not pay the fine and refuse to join a plan; they signed up in droves.

As another nice observation, the study found that racial and ethnic disparities in access to health care have largely disappeared in Massachusetts since the reform.

Political teapots are whistling on the left and right over the recent vote by the Massachusetts House of Representatives to put municipal workers in the pool run by the state for state employees (the Group Insurance Commission). I won’t delve into politics on the Radar site, and certainly not the “Wisconsin showdown” over collective bargaining. But I will list a few facts that need to be kept in light, after talking to a number of progressives who support both health care for all and strong unions.

  • When it comes to health care plans, bigger is better. Because it contains so many workers, the GIC is in an excellent bargaining position in relation to insurers and health care providers. In contrast, Massachusetts towns are hardly in a better position than small employers. So they’re desperate to combine their workers into a bigger pool. The main argument against joining is that, the more people combine into big pools and cut costs, the bigger is the burden on small employers and the self-insured. Some people follow this logic to demand a single-payer system, but I would just prefer to see more efficiency and less waste in the health care system.

  • Knowing that they could avoid cuts (including cuts in union jobs) by joining a bigger pool, towns have been feverishly negotiating for years with their unions to join the GIC, with few successes.

  • Joining a large pool would save so much money that the cities could devote extra money to filling any gap left by GIC coverage and still save a bundle.

To reiterate: we have to get costs down by cutting down on waste. Most providers in Massachusetts have electronic health record systems, putting us way ahead of most US states. But that’s just a start. Efficiency wasn’t built in.

Luckily, I’ve attended health care meetings where leaders in Massachusetts suggest that we can cut costs, even as a single and relatively small state. Besides the formation of ACOs, we can press doctors to institute measures that improve care and reduce mistakes. We can also educate the public to accept lower-cost care. They have to learn three big lessons:

  • A world-famous teaching hospital is not always better than a community hospital for a given procedure.
  • You don’t have to see a specialist for every condition.
  • You don’t need the newest medicines, machinery, and procedures.

Will the rest of this country follow Massachusetts to near-universal coverage and the benefits seen in the Blue Cross study? There are notable differences. Massachusetts started with a higher degree of insurance coverage than the rest of the country. We clearly offer some astonishing medical care (although the big-name institutions don’t always live up to their reputations). We have a relatively highly educated population, and population density makes it easier to provide doctors to everybody. But we still suffer from many of the same problems as health care in other parts of the US. So it will be worth comparing our experience to experiments in other states.

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  • Great article. Thanks for sharing.

    I was especially struck by the finding
    “As another nice observation, the study found that racial and ethnic disparities in access to health care have largely disappeared in Massachusetts since the reform.”

    This is a remarkable outcome given how elusive this has been. I doubt it will be as simple as expanding access but even if partly or mostly true, it is a start on erasing one of the the most tragic aspects of our health care “system”

  • Haroon Alvi

    While there is room for improvement on the payer and provider side of the equation, there is as great (if not greater) need for improvement on the patient side of the equation, i.e. compliance. After all, solving the problem at it’s source is likely more cost effective then correcting the problem further down the line.

    Consider that in the past 20 years more than 50% of the US population has become overweight, obese or morbidly obese, and this single condition is related to diabetes and circulatory conditions that are the major (>50%) drivers of Medicare’s spend. In my unscientific survey of physicians, they have many frustrations, but one of their leading frustrations is patient non-compliance.

    In this context, a major hospital in my area now makes overweight, diabetic patients with wound care issues sign a piece of paper requiring that they comply with the physician’s directives, or they will be discharged from any further care. Part of this driven by a growing realization from payers like Medicare, that paying for results is more effective than paying for service. But physicians also wants to do good, and at some point a physician realizes that they cannot help a patient who won’t help themselves.

  • I really appreciate all the expert comments (hi, Felasfa!) and I hope
    everybody returns to Radar each day this week for a long series I’m
    blogging about genetics research. Abhi’s questions are really the
    issues of the moment. I don’t know the answer regarding patient
    outcomes, and it may be too early to measure that–we might not even
    have instruments in place to collect the data.

    I did mention in the article that Blue Cross is asking people to move
    to a more ACO-like plan. We have near-universal care in Massachusetts,
    but we’re far from having coordinated care. And it’s also time for
    hospitals and providers to get really serious about doing the things
    that Donald Berwick has been talking about for years. Maybe now that
    he’s unfortunately being kicked out of Washington, he’ll come back
    here to Boston and lead the charge.

  • Mass Doctor

    No comment on the one in three medical errors or injuries? Fraud? Patient abuse? Patient abandonment? Hate crimes?

    Containing costs involves radical improvements in care, specifically, active pursuit of fraud and patient abuse which has not occurred in the state. Patients are subjected to violent personality-disordered doctors with no accountability. Injuries, including those involving manslaughter of disabled patients, are not reported or lied about in the medical record. The culture of psychopathic careerism at Harvard, and elsewhere in the state, means that patients suffer while some very malevolent doctors end up on the “Best Doctors” or “Top Doctors” lists. One doctor has sexually assaulted multiple women patients with indecent A&B of the breasts for years with no containment, criminal charges or return of funds. Another doctor, a psychiatrist, repeatedly raped a disabled female psych patient, was never criminally charged and now works as a “medical writer” for PAREXEL after losing his license. The ERs are highly malevolent places where nasty attitudes and acting out on patients prevail. Women’s voices are silenced. Governor Patrick has refused to investigate severe violence against women and patients at the state medical center, despite state and federal funding. The state has been slow to contain dangerous fraudulent clinical activity that has been going on for years. Provider safety continues to be compromised. Law enforcement personnel are still untrained in how to perform proper restraint, even in hospitals. Whistle-blowers are battered.

    The American health care system is about neither health, nor care: it’s a system set up to dominate, concentrate money and power upwards, and denigrate and devalue the patient. Nothing happening in Massachusetts has changed that.